Healthcare Provider Details

I. General information

NPI: 1295733491
Provider Name (Legal Business Name): BLACK ROCK TPK MED GRP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5520 PARK AVE SUITE 203
TRUMBULL CT
06611-3463
US

IV. Provider business mailing address

5520 PARK AVE SUITE 203
TRUMBULL CT
06611-3463
US

V. Phone/Fax

Practice location:
  • Phone: 203-334-7400
  • Fax: 203-338-0455
Mailing address:
  • Phone: 203-334-7400
  • Fax: 203-338-0455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number013894
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: ELIZABETH FERNANDEZ
Title or Position: OFFICE ADMINISTRATOR
Credential:
Phone: 203-334-7400