Healthcare Provider Details

I. General information

NPI: 1902195019
Provider Name (Legal Business Name): CONNECTICUT EPILEPSY GROUP PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2011
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

733 SUMMER ST SUITE 301
STAMFORD CT
06901-1081
US

IV. Provider business mailing address

690 N BROADWAY SUITE GL1
WHITE PLAINS NY
10603-2417
US

V. Phone/Fax

Practice location:
  • Phone: 914-428-3651
  • Fax: 914-428-2948
Mailing address:
  • Phone: 914-428-3651
  • Fax: 914-428-2948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. MARCELO E LANCMAN
Title or Position: DIRECTOR
Credential: MD
Phone: 914-428-3651