Healthcare Provider Details

I. General information

NPI: 1033220108
Provider Name (Legal Business Name): PEDIATRICS AND ADOLESCENT MEDICINE, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 10/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 INDIAN RIVER RD SUITE B-1
ORANGE CT
06477-3649
US

IV. Provider business mailing address

240 INDIAN RIVER RD SUITE B-1
ORANGE CT
06477-3649
US

V. Phone/Fax

Practice location:
  • Phone: 203-795-4924
  • Fax: 203-799-1554
Mailing address:
  • Phone: 203-795-4924
  • Fax: 203-799-1554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: JONATHAN CHARRON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 203-795-4924