=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275948887
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FAIRFIELD PSYCHIATRY,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2014
-----------------------------------------------------
Last Update Date | 06/23/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 60 THORPE ST FL 2 FAIRFIELD
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-5725
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-763-4769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 90
-----------------------------------------------------
City | FAIRFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06824-0090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-763-4769
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MIHAELA NEDELCUTA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-763-4769
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 049472
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------