Healthcare Provider Details

I. General information

NPI: 1962680934
Provider Name (Legal Business Name): NEW HAVEN PEDIATRIC & ADOLESCENT MEDICAL SERV
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 02/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1423 CHAPEL ST UNIT 2B
NEW HAVEN CT
06511
US

IV. Provider business mailing address

1423 CHAPEL ST UNIT 2B
NEW HAVEN CT
06511
US

V. Phone/Fax

Practice location:
  • Phone: 203-752-0706
  • Fax: 203-772-0387
Mailing address:
  • Phone: 203-752-0706
  • Fax: 203-772-0387

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0136872
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number0002815
License Number StateCT

VIII. Authorized Official

Name: ANGEL JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-906-3854