Healthcare Provider Details

I. General information

NPI: 1821173337
Provider Name (Legal Business Name): JAMES R SEIBOLD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 05/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

263 FARMINGTON AVE MARB MC5353 RM N3020
FARMINGTON CT
06030-0002
US

IV. Provider business mailing address

65 KANE ST PROVIDER ENROLLMENT - ELLIE ATKINS
WEST HARTFORD CT
06119-2110
US

V. Phone/Fax

Practice location:
  • Phone: 860-679-3605
  • Fax: 860-679-1042
Mailing address:
  • Phone: 860-523-6421
  • Fax: 860-523-3701

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number048454
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number048454
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: