Healthcare Provider Details

I. General information

NPI: 1578556486
Provider Name (Legal Business Name): SHAMMI K BALI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 09/22/2025
Certification Date: 09/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 TALCOTTVILLE RD
VERNON CT
06066-4617
US

IV. Provider business mailing address

206 TALCOTTVILLE RD
VERNON CT
06066-4617
US

V. Phone/Fax

Practice location:
  • Phone: 860-645-1100
  • Fax: 860-533-0041
Mailing address:
  • Phone: 860-645-1100
  • Fax: 860-533-0041

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number83043
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: