Healthcare Provider Details

I. General information

NPI: 1659585149
Provider Name (Legal Business Name): SOUTHINGTON PEDIATRIC ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

209 MAIN ST 1ST FLOOR
SOUTHINGTON CT
06489
US

IV. Provider business mailing address

209 MAIN ST 1ST FLOOR
SOUTHINGTON CT
06489
US

V. Phone/Fax

Practice location:
  • Phone: 860-621-8331
  • Fax: 860-621-5169
Mailing address:
  • Phone: 860-621-8331
  • Fax: 860-621-5169

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number021344
License Number StateCT

VIII. Authorized Official

Name: MR. GEORGE SKARVINKO
Title or Position: MD OWNER OF PRACTICE
Credential: MD
Phone: 860-621-8331