Healthcare Provider Details

I. General information

NPI: 1649435900
Provider Name (Legal Business Name): JOHN DEMPSEY HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/25/2008
Last Update Date: 07/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

IV. Provider business mailing address

263 FARMINGTON AVE
FARMINGTON CT
06030-0001
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-4450
  • Fax:
Mailing address:
  • Phone: 860-679-4450
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number03-637643
License Number StateCT

VIII. Authorized Official

Name: MR. JIUSEPPE M RUSSO
Title or Position: REGISTERED DIETITIAN
Credential: R.D.
Phone: 860-679-4450