Healthcare Provider Details

I. General information

NPI: 1700340106
Provider Name (Legal Business Name): ROBERT CHRISTOPHER SCALISE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2019
Last Update Date: 01/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

59 SEQUIN DR
GROTON CT
06340-5510
US

IV. Provider business mailing address

1 WAHOO DRIVE MEDICAL CLINIC, OCCUPATIONAL HEALTH
GROTON CT
06349
US

V. Phone/Fax

Practice location:
  • Phone: 619-882-9148
  • Fax:
Mailing address:
  • Phone: 860-694-4910
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number5101018005
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: