=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558699256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | IAN R CAMERON MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/18/2009
-----------------------------------------------------
Last Update Date | 11/18/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2174 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-3602
-----------------------------------------------------
Fax | 860-657-4421
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2174 MAIN ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2206
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-3602
-----------------------------------------------------
Fax | 860-657-4421
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. IAN RICHARD CAMERON
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-657-3602
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM0850X
-----------------------------------------------------
Taxonomy Name | Adult Mental Health Clinic/Center
-----------------------------------------------------
License Number | 011816
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------