Healthcare Provider Details

I. General information

NPI: 1174005219
Provider Name (Legal Business Name): EAR SPECIALTY GROUP OF CONNECTICUT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2018
Last Update Date: 11/02/2023
Certification Date: 11/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 STANFORD DR
FARMINGTON CT
06032-2454
US

IV. Provider business mailing address

40 STANFORD DR
FARMINGTON CT
06032-2454
US

V. Phone/Fax

Practice location:
  • Phone: 860-640-4455
  • Fax: 860-640-4478
Mailing address:
  • Phone: 860-640-4455
  • Fax: 860-640-4478

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207YX0901X
TaxonomyOtology & Neurotology Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN HANNAH ROSTRON
Title or Position: DIRECTOR OF OPERATIONS
Credential: AUD
Phone: 860-640-4455