Healthcare Provider Details

I. General information

NPI: 1508375064
Provider Name (Legal Business Name): CIVIC WILTON, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2017
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

249 DANBURY ROAD
WILTON CT
06897
US

IV. Provider business mailing address

249 DANBURY RD
WILTON CT
06897-4070
US

V. Phone/Fax

Practice location:
  • Phone: 816-537-3433
  • Fax: 816-537-3431
Mailing address:
  • Phone: 816-537-3431
  • Fax: 816-537-3431

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number039079
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT M ROTEMAN
Title or Position: PARTNER
Credential: MD
Phone: 816-537-3433