Healthcare Provider Details

I. General information

NPI: 1891749933
Provider Name (Legal Business Name): HEALTHWISE MEDICAL ASSOCIATES, LLP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2006
Last Update Date: 05/15/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 NAEK RD SUITE 5
VERNON CT
06066-3942
US

IV. Provider business mailing address

PO BOX 3249
VERNON CT
06066-2149
US

V. Phone/Fax

Practice location:
  • Phone: 860-872-2289
  • Fax: 860-896-1425
Mailing address:
  • Phone: 860-896-1422
  • Fax: 860-896-1425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number000765
License Number StateCT

VIII. Authorized Official

Name: RENEE IRVIN
Title or Position: CEO
Credential:
Phone: 860-872-2289