=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366882037
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THOMAS BAIRD FITZGERALD D.O.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/26/2013
-----------------------------------------------------
Last Update Date | 07/29/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 HAZARD AVE
-----------------------------------------------------
City | ENFIELD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06082-4520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-763-4001
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11 SAGAMORE LN UNIT 207
-----------------------------------------------------
City | ROCKY HILL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06067-3847
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-478-6339
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 56667
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------