Healthcare Provider Details

I. General information

NPI: 1396075933
Provider Name (Legal Business Name): THE INSTITUTE FOR NEURODEGENERATIVE DISORDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2010
Last Update Date: 01/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 TEMPLE ST SUITE 8B
NEW HAVEN CT
06510-2716
US

IV. Provider business mailing address

60 TEMPLE ST SUITE 8B
NEW HAVEN CT
06510-2716
US

V. Phone/Fax

Practice location:
  • Phone: 203-401-4300
  • Fax: 203-401-4304
Mailing address:
  • Phone: 203-401-4300
  • Fax: 203-401-4304

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084D0003X
TaxonomyDiagnostic Neuroimaging (Psychiatry & Neurology) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. JACK M MARIOTTI
Title or Position: CFO
Credential: CPA
Phone: 203-401-4351