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General NPI Number Information
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NPI Number | 1841498839
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Entity Type | Organization
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Legal Business Name | STAYWELL PEDIATRIC LLC
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Dates
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Enumeration Date | 07/11/2007
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Last Update Date | 07/11/2007
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Provider Practice Location Address
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Address Line | 365 ELM ST
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City | WEST HAVEN
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State | CT
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Zip | 06516-4217
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Country | US
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Telephone | 203-932-3227
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Fax |
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Provider Business Mailing Address
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Address Line | 365 ELM ST
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City | WEST HAVEN
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State | CT
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Zip | 06516-4217
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Country | US
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Telephone | 203-932-3227
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. THOMAS ETKIN
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Credential | M.D.
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Telephone | 203-932-3227
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2080A0000X
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Taxonomy Name | Pediatric Adolescent Medicine Physician
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License Number | 01775
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License Number State | CT
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