Healthcare Provider Details

I. General information

NPI: 1790781078
Provider Name (Legal Business Name): SUSAN F BURROUGHS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2005
Last Update Date: 09/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 TALCOTTVILLE RD # 1
VERNON CT
06066-4051
US

IV. Provider business mailing address

196 PARKWAY S SUITE 304
WATERFORD CT
06385-1234
US

V. Phone/Fax

Practice location:
  • Phone: 860-896-4718
  • Fax: 860-896-1426
Mailing address:
  • Phone: 860-442-7027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number030948
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: