Healthcare Provider Details

I. General information

NPI: 1275897340
Provider Name (Legal Business Name): FAIRFIELD MEDICAL MANAGEMENT GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2012
Last Update Date: 07/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2890 MAIN ST STE 2A
STRATFORD CT
06614-4980
US

IV. Provider business mailing address

2890 MAIN ST STE 2A
STRATFORD CT
06614-4980
US

V. Phone/Fax

Practice location:
  • Phone: 203-633-4560
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MATTHIAS V RALABATE
Title or Position: MEMBER
Credential:
Phone: 203-633-4560