Healthcare Provider Details

I. General information

NPI: 1518121623
Provider Name (Legal Business Name): RUSSELL W. ROBERTSON, M.D.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2008
Last Update Date: 07/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 519
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

85 SEYMOUR ST SUITE 519
HARTFORD CT
06106-5501
US

V. Phone/Fax

Practice location:
  • Phone: 860-246-1203
  • Fax: 860-246-1145
Mailing address:
  • Phone: 860-246-1203
  • Fax: 860-246-1145

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number16087
License Number StateCT

VIII. Authorized Official

Name: DR. RUSSELL WRIGHT ROBERTSON
Title or Position: OWNER
Credential: M.D.
Phone: 860-246-1203