Healthcare Provider Details

I. General information

NPI: 1568770477
Provider Name (Legal Business Name): GREENWICH PLASTIC SURGERY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2010
Last Update Date: 09/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 1/2 DEARFIELD DR
GREENWICH CT
06831-5335
US

IV. Provider business mailing address

2 1/2 DEARFIELD DR
GREENWICH CT
06831-5335
US

V. Phone/Fax

Practice location:
  • Phone: 203-629-1900
  • Fax: 212-207-9252
Mailing address:
  • Phone: 203-629-1900
  • Fax: 212-207-9252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number0404243
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2082S0105X
TaxonomySurgery of the Hand (Plastic Surgery) Physician
License Number0404243
License Number StateCT

VIII. Authorized Official

Name: STEVEN A FERN
Title or Position: OWNER
Credential: M.D.
Phone: 203-629-1900