Healthcare Provider Details

I. General information

NPI: 1518098698
Provider Name (Legal Business Name): STAFFORD MEDICAL GROUP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/08/2007
Last Update Date: 01/29/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 MAIN ST
SOMERS CT
06071-1825
US

IV. Provider business mailing address

146 MAIN ST
SOMERS CT
06071-1825
US

V. Phone/Fax

Practice location:
  • Phone: 860-749-8018
  • Fax: 860-316-4015
Mailing address:
  • Phone: 860-749-8018
  • Fax: 860-316-4015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30076
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number30076
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5393
License Number StateCT

VIII. Authorized Official

Name: DR. SULTAN ALAM QURAISHI
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 860-558-3624