=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306087838
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DANBURY PHYSICAL MEDICINE AND REHABILITATION PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2009
-----------------------------------------------------
Last Update Date | 12/02/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 109 NEWTON RD SUITE 1
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-207-9840
-----------------------------------------------------
Fax | 203-207-9849
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 109 NEWTON RD SUITE 1
-----------------------------------------------------
City | DANBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06810-4120
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-207-9840
-----------------------------------------------------
Fax | 203-207-9849
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MS. NIKKI C BLAYZOR
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-207-9840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 043130
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------