Healthcare Provider Details

I. General information

NPI: 1639137946
Provider Name (Legal Business Name): PER DIEM PA SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 STRAITS TPKE
MIDDLEBURY CT
06762-1835
US

IV. Provider business mailing address

137 DANBURY RD
NEW MILFORD CT
06776-3428
US

V. Phone/Fax

Practice location:
  • Phone: 203-754-0065
  • Fax:
Mailing address:
  • Phone: 203-770-1610
  • Fax: 860-355-7373

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MR. GREGORY A WOLFF
Title or Position: SECRETARY
Credential:
Phone: 203-984-7889