Healthcare Provider Details

I. General information

NPI: 1043451214
Provider Name (Legal Business Name): WARREN PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2009
Last Update Date: 07/23/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

81 S MAIN ST STE 5
WEST HARTFORD CT
06107-2400
US

IV. Provider business mailing address

81 S MAIN ST STE 5
WEST HARTFORD CT
06107-2400
US

V. Phone/Fax

Practice location:
  • Phone: 860-521-4044
  • Fax: 860-521-3885
Mailing address:
  • Phone: 860-521-4044
  • Fax: 860-521-3885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number042022
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. MATTHEW SCOTT WARREN
Title or Position: MEMBER
Credential: MD
Phone: 860-521-4044