MEDICARE: SOUTHERN CONNECTICUT GERIATRIC & PREVENTIVE MEDICINE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2083P0901X	Public Health & General Preventive Medicine Physician	041288	CT
2	207RG0300X	Geriatric Medicine (Internal Medicine) Physician
3	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	041288	CT

General Provider Information

NPI Number	:	1679701882
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOUTHERN CONNECTICUT GERIATRIC & PREVENTIVE MEDICINE LLC

Provider Business Mailing Address
First Line	:	390 LIVINGSTON ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-1336
Country	:	US
Telephone Number	:	203-871-9224
Fax Number	:

Provider Business Practice Location Address
First Line	:	390 LIVINGSTON ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06511-1336
Country	:	US
Telephone Number	:	203-871-9224
Fax Number	:

Authorized Official
Title or Position	:	MEMBER
Name	:	DR. ASEFEH HEIAT
Credential	:	M.D., M.P.H.
Telephone Number	:	203-871-9224

Provider Enumeration Date	:	06/25/2009
Last Update Date	:	10/04/2021

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