Healthcare Provider Details

I. General information

NPI: 1962763722
Provider Name (Legal Business Name): CARDIOLOGY PHYSICIANS OF FAIRFIELD COUNTY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2012
Last Update Date: 11/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 SUMMER ST
STAMFORD CT
06905-5572
US

IV. Provider business mailing address

2800 MAIN ST
BRIDGEPORT CT
06606-4201
US

V. Phone/Fax

Practice location:
  • Phone: 203-353-1133
  • Fax:
Mailing address:
  • Phone: 203-576-5551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN GLECKLER
Title or Position: CFO
Credential:
Phone: 203-576-5551