=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528473519
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STAMFORD PHYSICAL MEDICINE PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2014
-----------------------------------------------------
Last Update Date | 02/05/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 90 MORGAN ST SUITE 203
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-5466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-325-0174
-----------------------------------------------------
Fax | 203-325-3551
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 90 MORGAN ST SUITE 203
-----------------------------------------------------
City | STAMFORD
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06905-5466
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-325-0174
-----------------------------------------------------
Fax | 203-325-3551
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | RICHARD INGLIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 203-325-0174
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 033974
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------