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General NPI Number Information
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NPI Number | 1245410406
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Entity Type | Organization
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Legal Business Name | INTERNAL MEDICINE SPECIALISTS
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Dates
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Enumeration Date | 11/05/2007
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Last Update Date | 05/21/2015
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Provider Practice Location Address
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Address Line | 1389 W MAIN ST STE 224
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City | WATERBURY
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State | CT
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Zip | 06708-3104
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Country | US
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Telephone | 203-597-0393
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Fax |
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Provider Business Mailing Address
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Address Line | 1389 WEST MAIN ST STE 224
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City | WATERBURY
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State | CT
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Zip | 06708-0000
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Country | US
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Telephone | 203-597-0393
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. LAURA A REILLY
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Credential |
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Telephone | 203-597-0393
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 19477
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 207RE0101X
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Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
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License Number | 19477
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License Number State | CT
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Taxonomy #3
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 003751
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License Number State | CT
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