Healthcare Provider Details

I. General information

NPI: 1649391046
Provider Name (Legal Business Name): NUTMEG HEALTHCARE ASSOCIATES, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 10/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 E MAIN ST
STAFFORD SPRINGS CT
06076-1227
US

IV. Provider business mailing address

15 PALOMBA DR STE 4
ENFIELD CT
06082-3853
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5848
  • Fax:
Mailing address:
  • Phone: 860-741-0764
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number029923
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: DR. ROBERT D. CARLSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 860-429-8439