Healthcare Provider Details

I. General information

NPI: 1679605471
Provider Name (Legal Business Name): LONG WHARF PEDIATRICS & ADOLESCENT MEDICINE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 06/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SARGENT DR STE 6
NEW HAVEN CT
06511-6100
US

IV. Provider business mailing address

150 SARGENT DR STE 6
NEW HAVEN CT
06511-6100
US

V. Phone/Fax

Practice location:
  • Phone: 203-781-4321
  • Fax: 203-781-4329
Mailing address:
  • Phone: 203-781-4321
  • Fax: 203-781-4329

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. LUCILLE A SEMERARO
Title or Position: MEMBER
Credential: MD
Phone: 203-781-4321