=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245407352
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BERLIN PEDIATRIC ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/08/2008
-----------------------------------------------------
Last Update Date | 05/08/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 742 WORTHINGTON RDG SUITE A
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-829-7337
-----------------------------------------------------
Fax | 860-829-2295
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 742 WORTHINGTON RDG SUITE A
-----------------------------------------------------
City | BERLIN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06037-3233
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-829-7337
-----------------------------------------------------
Fax | 860-829-2295
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SOLE MEMBER
-----------------------------------------------------
Name | DR. MATTEO JOSEPH LOPREIATO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-829-7337
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 041963
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------