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General NPI Number Information
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NPI Number | 1043482128
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Entity Type | Organization
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Legal Business Name | LEIF O NORDBERG MD, LLC
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Dates
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Enumeration Date | 03/28/2008
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Last Update Date | 08/22/2018
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Provider Practice Location Address
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Address Line | 2001 W MAIN ST SUITE 155
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City | STAMFORD
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State | CT
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Zip | 06902
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Country | US
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Telephone | 203-324-4700
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Fax | 203-324-5691
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Provider Business Mailing Address
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Address Line | 2001 W MAIN ST SUITE 155
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City | STAMFORD
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State | CT
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Zip | 06902-4501
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Country | US
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Telephone | 203-324-1971
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. LEIF O NORDBERG
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Credential | M.D.
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Telephone | 203-324-1971
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 349
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License Number State | CT
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