Healthcare Provider Details

I. General information

NPI: 1245410406
Provider Name (Legal Business Name): INTERNAL MEDICINE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2007
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1389 W MAIN ST STE 224
WATERBURY CT
06708-3104
US

IV. Provider business mailing address

1389 WEST MAIN ST STE 224
WATERBURY CT
06708-0000
US

V. Phone/Fax

Practice location:
  • Phone: 203-597-0393
  • Fax:
Mailing address:
  • Phone: 203-597-0393
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19477
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number19477
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number003751
License Number StateCT

VIII. Authorized Official

Name: MRS. LAURA A REILLY
Title or Position: MANAGER
Credential:
Phone: 203-597-0393