Healthcare Provider Details

I. General information

NPI: 1922251107
Provider Name (Legal Business Name): DERMATOLOGY IN HAMDEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2008
Last Update Date: 10/31/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2880 OLD DIXWELL AVE
HAMDEN CT
06518-3144
US

IV. Provider business mailing address

2880 OLD DIXWELL AVE
HAMDEN CT
06518-3144
US

V. Phone/Fax

Practice location:
  • Phone: 203-288-5624
  • Fax: 203-288-7782
Mailing address:
  • Phone: 203-288-5624
  • Fax: 203-288-7782

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number035147
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number035147
License Number StateCT

VIII. Authorized Official

Name: DR. PETER SHERLINE
Title or Position: BUSINESS MANAGER
Credential: M.D.
Phone: 860-677-4539