Healthcare Provider Details

I. General information

NPI: 1417680984
Provider Name (Legal Business Name): ALEX I ROYTBURG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2022
Last Update Date: 02/13/2023
Certification Date: 02/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

76 POCAHONTAS DR
WEST HARTFORD CT
06117-1441
US

IV. Provider business mailing address

76 POCAHONTAS DR
WEST HARTFORD CT
06117-1441
US

V. Phone/Fax

Practice location:
  • Phone: 860-798-3705
  • Fax:
Mailing address:
  • Phone: 860-798-3705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number10.120090
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10744
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: