=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093561136
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NOVA PHYSICIAN GROUP PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/29/2024
-----------------------------------------------------
Last Update Date | 12/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 N MAIN ST
-----------------------------------------------------
City | WATERBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06704-2364
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-951-8306
-----------------------------------------------------
Fax | 475-215-3374
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 745254
-----------------------------------------------------
City | ATLANTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30374-5254
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-352-1515
-----------------------------------------------------
Fax | 312-929-0373
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SR. MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. TERRENCE MORTON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 773-352-1515
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------