Healthcare Provider Details

I. General information

NPI: 1003856048
Provider Name (Legal Business Name): MANCHESTER EAR, NOSE & THROAT CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 TAMARACK AVE SUITE 102
SOUTH WINDSOR CT
06074-9999
US

IV. Provider business mailing address

2800 TAMARACK AVE SUITE 102
SOUTH WINDSOR CT
06074-9999
US

V. Phone/Fax

Practice location:
  • Phone: 860-648-0860
  • Fax: 860-648-0870
Mailing address:
  • Phone: 860-648-0860
  • Fax: 860-648-0870

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number040529
License Number StateCT

VIII. Authorized Official

Name: MICHAEL A SHTERNFELD
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 860-648-0860