Healthcare Provider Details

I. General information

NPI: 1922500412
Provider Name (Legal Business Name): CENTER FOR DIABETES EXCELLENCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PURDY HILL RD STE 2
MONROE CT
06468-1661
US

IV. Provider business mailing address

530 SCENIC RD
ORANGE CT
06477-2127
US

V. Phone/Fax

Practice location:
  • Phone: 203-261-4277
  • Fax:
Mailing address:
  • Phone: 203-909-0016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number1425
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number1425
License Number StateCT

VIII. Authorized Official

Name: JOANN HICKEY AHERN
Title or Position: APRN
Credential: MSN
Phone: 203-261-4277