Healthcare Provider Details

I. General information

NPI: 1326331471
Provider Name (Legal Business Name): CIRCULATORY CENTERS CONNECTICUT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2011
Last Update Date: 09/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 HUNTLEY RD SUITE 1
OLD LYME CT
06371-1449
US

IV. Provider business mailing address

397 CHURCHILL HUBBARD RD
YOUNGSTOWN OH
44505-1375
US

V. Phone/Fax

Practice location:
  • Phone: 860-434-4073
  • Fax: 860-434-4635
Mailing address:
  • Phone: 330-759-6750
  • Fax: 330-759-6755

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number005169
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number039899
License Number StateCT

VIII. Authorized Official

Name: DR. LOUIS MICHAEL CERTO
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 412-967-9220