Healthcare Provider Details

I. General information

NPI: 1790987709
Provider Name (Legal Business Name): LEIGH ROWAN-KELLY MD FASAM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MICHAEL CHARLES LEIGH ROWAN-KELLY MD FASAM

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 12/27/2024
Certification Date: 12/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 ISLAND DOCK RD
HADDAM CT
06438-1036
US

IV. Provider business mailing address

100 SUMMIT CREST DR
SOUTH GLASTONBURY CT
06073-2944
US

V. Phone/Fax

Practice location:
  • Phone: 816-416-6168
  • Fax: 860-430-2672
Mailing address:
  • Phone: 816-416-6168
  • Fax: 860-430-2672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number68097
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: