Healthcare Provider Details

I. General information

NPI: 1548625569
Provider Name (Legal Business Name): SOUND BEACH PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2015
Last Update Date: 08/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 W MAIN ST SUITE 132
STAMFORD CT
06902-4501
US

IV. Provider business mailing address

2001 W MAIN ST SUITE 132
STAMFORD CT
06902-4501
US

V. Phone/Fax

Practice location:
  • Phone: 203-331-2044
  • Fax: 475-619-9855
Mailing address:
  • Phone: 203-363-0123
  • Fax: 475-619-9855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number041814
License Number StateCT

VIII. Authorized Official

Name: DR. KATHERINE NOBLE
Title or Position: MD
Credential: MD
Phone: 203-363-0123