Healthcare Provider Details

I. General information

NPI: 1710163795
Provider Name (Legal Business Name): EMMANUEL KENTA-BIBI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2008
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 S MAIN ST FAMILY PRACTICE GROUP
MIDDLETOWN CT
06457-3649
US

IV. Provider business mailing address

90 S MAIN ST FAMILY PRACTICE GROUP
MIDDLETOWN CT
06457-3649
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6300
  • Fax: 860-344-9249
Mailing address:
  • Phone: 860-358-6300
  • Fax: 860-344-9249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number047740
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number47740
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: