Healthcare Provider Details

I. General information

NPI: 1386158467
Provider Name (Legal Business Name): PM PEDIATRICS OF CONNECTICUT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2017
Last Update Date: 01/21/2025
Certification Date: 01/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1459 NEW BRITAIN AVE
WEST HARTFORD CT
06110-1659
US

IV. Provider business mailing address

1 HOLLOW LN STE 301
NEW HYDE PARK NY
11042-1215
US

V. Phone/Fax

Practice location:
  • Phone: 860-232-5437
  • Fax: 860-232-2110
Mailing address:
  • Phone: 516-869-0650
  • Fax: 516-673-9408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DANIELLE MARIE LOPEZ
Title or Position: MANAGER CREDENTIALING/ENROLLMENT
Credential:
Phone: 516-207-7936