=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538469499
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLESEX DIABETES & ENDOCRINOLOGY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/26/2010
-----------------------------------------------------
Last Update Date | 10/26/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 540 SAYBROOK RD SUITE 150
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-346-3308
-----------------------------------------------------
Fax | 860-346-3349
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 540 SAYBROOK RD SUITE 150
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-4711
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-346-3308
-----------------------------------------------------
Fax | 860-346-3349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/DIRECTOR
-----------------------------------------------------
Name | KORT CHRISTOPHER KNUDSON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-346-3308
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RE0101X
-----------------------------------------------------
Taxonomy Name | Endocrinology, Diabetes & Metabolism Physician
-----------------------------------------------------
License Number | 020696
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------