=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760714661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INTEGRATED MEDICAL OF NEW HAVEN, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/03/2010
-----------------------------------------------------
Last Update Date | 02/03/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 111 PARK ST SUITE 1C
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-773-1935
-----------------------------------------------------
Fax | 203-773-0039
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 111 PARK ST SUITE 1C
-----------------------------------------------------
City | NEW HAVEN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06511-5412
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-773-1935
-----------------------------------------------------
Fax | 203-773-0039
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DR. MICHAEL LANCE GERSTENFELD
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 203-773-1935
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Internal Medicine) Physician
-----------------------------------------------------
License Number | 031959
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------