=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407255847
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SUPERIOR ASSOCIATES, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/21/2014
-----------------------------------------------------
Last Update Date | 07/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 106 NOROTON AVE INFUSION
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-309-5399
-----------------------------------------------------
Fax | 203-656-1416
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 106 NOROTON AVE INFUSION
-----------------------------------------------------
City | DARIEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-309-5399
-----------------------------------------------------
Fax | 203-656-1416
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEDICAL DIRECTOR
-----------------------------------------------------
Name | DR. DENIS BOUBOULIS
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 203-309-5399
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207K00000X
-----------------------------------------------------
Taxonomy Name | Allergy & Immunology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------