Healthcare Provider Details

I. General information

NPI: 1215164058
Provider Name (Legal Business Name): SOUTHERN NEW ENGLAND EAR, NOSE, THROAT AND FACIAL PLASTIC SURGERY GROU
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2009
Last Update Date: 11/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE LONG WHARF DRIVE SUITE #302
NEW HAVEN CT
06511-5593
US

IV. Provider business mailing address

ONE LONG WHARF DRIVE SUITE #302
NEW HAVEN CT
06511-5593
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7500
  • Fax: 203-777-8469
Mailing address:
  • Phone: 203-777-7500
  • Fax: 203-777-8469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number034314
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. EIIZABETH IRENE SULLIVAN
Title or Position: CEO
Credential:
Phone: 203-777-7500