Healthcare Provider Details

I. General information

NPI: 1902279607
Provider Name (Legal Business Name): PRIMARY CARE PHYSICIANS OF STRATFORD, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/04/2015
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2660 MAIN ST SUITE 216
BRIDGEPORT CT
06606-5369
US

V. Phone/Fax

Practice location:
  • Phone: 203-378-3696
  • 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 Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: CHRISTOPHER L WILLEY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 203-576-5076