Healthcare Provider Details

I. General information

NPI: 1023102209
Provider Name (Legal Business Name): PHYSICAL MEDICINE AND CHIROPRACTIC CENTER LORELEI DAVIDSON M.D. MARC K
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 03/11/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1867 SUMMER ST
STAMFORD CT
06905-5016
US

IV. Provider business mailing address

1867 SUMMER ST
STAMFORD CT
06905-5016
US

V. Phone/Fax

Practice location:
  • Phone: 203-975-7000
  • Fax: 203-975-0876
Mailing address:
  • Phone: 203-975-7000
  • Fax: 203-975-0876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number044106
License Number StateCT

VIII. Authorized Official

Name: DR. MARC DAVID KIRSHNER
Title or Position: PRESIDENT
Credential: D.C.
Phone: 203-975-7000