Healthcare Provider Details

I. General information

NPI: 1295053502
Provider Name (Legal Business Name): CONNECTICUT PHLEBOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 02/08/2022
Certification Date: 02/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 SASCO HILL RD STE 2
FAIRFIELD CT
06824-5670
US

IV. Provider business mailing address

2015 SPRING RD STE 300
OAK BROOK IL
60523-3944
US

V. Phone/Fax

Practice location:
  • Phone: 203-256-0070
  • Fax:
Mailing address:
  • Phone: 630-725-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number StateCT
# 5
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: CYNTHIA JONES
Title or Position: CREDENTIALING
Credential:
Phone: 630-725-2737