Healthcare Provider Details

I. General information

NPI: 1053215574
Provider Name (Legal Business Name): MR. SPENCER GUSTAVE SCHALLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

275 NEW STATE RD
MANCHESTER CT
06042-1810
US

IV. Provider business mailing address

76 FAR HILLS DR
AVON CT
06001-2877
US

V. Phone/Fax

Practice location:
  • Phone: 860-647-9798
  • Fax:
Mailing address:
  • Phone: 860-948-8686
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number4586
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: