Healthcare Provider Details

I. General information

NPI: 1760714661
Provider Name (Legal Business Name): INTEGRATED MEDICAL OF NEW HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2010
Last Update Date: 02/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 PARK ST SUITE 1C
NEW HAVEN CT
06511-5412
US

IV. Provider business mailing address

111 PARK ST SUITE 1C
NEW HAVEN CT
06511-5412
US

V. Phone/Fax

Practice location:
  • Phone: 203-773-1935
  • Fax: 203-773-0039
Mailing address:
  • Phone: 203-773-1935
  • Fax: 203-773-0039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License Number031959
License Number StateCT

VIII. Authorized Official

Name: DR. MICHAEL LANCE GERSTENFELD
Title or Position: MANAGER
Credential: MD
Phone: 203-773-1935