=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710152624
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STEPHEN R HOLZMAN, MD LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/23/2008
-----------------------------------------------------
Last Update Date | 04/23/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 OAK ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-8868
-----------------------------------------------------
Fax | 860-657-8802
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 OAK ST
-----------------------------------------------------
City | GLASTONBURY
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06033-2320
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-657-8868
-----------------------------------------------------
Fax | 860-657-8802
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | DR. STEPHEN R HOLZMAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-657-8868
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 023958
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------