Healthcare Provider Details

I. General information

NPI: 1639235609
Provider Name (Legal Business Name): TRACY G CIVITILLO MHS, PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 BLUE HILLS AVE
HARTFORD CT
06112-1500
US

IV. Provider business mailing address

71 HICKORY HILL RD
SIMSBURY CT
06070-2832
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4000
  • Fax:
Mailing address:
  • Phone: 860-306-2087
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number000974
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: