Healthcare Provider Details

I. General information

NPI: 1053612911
Provider Name (Legal Business Name): MANCHESTER PEDIATRIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/09/2010
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2701 TAMARACK AVE
SOUTH WINDSOR CT
06074-5561
US

IV. Provider business mailing address

2701 TAMARACK AVE
SOUTH WINDSOR CT
06074-5561
US

V. Phone/Fax

Practice location:
  • Phone: 860-647-8282
  • Fax: 860-647-8399
Mailing address:
  • Phone: 860-647-8282
  • Fax: 860-647-8399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number043564
License Number StateCT

VIII. Authorized Official

Name: SWATHANTHRA KUMAR MELEKOTE
Title or Position: OWNER
Credential: MD
Phone: 860-647-8282