Provider Demographics
NPI:1043341621
Name:MAIN STREET PEDIATRICS, PC
Entity Type:Organization
Organization Name:MAIN STREET PEDIATRICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:E
Authorized Official - Last Name:SCHUTZENGEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-371-7111
Mailing Address - Street 1:3180 MAIN ST
Mailing Address - Street 2:MAIN STREET PEDIATRICS, PC
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-4237
Mailing Address - Country:US
Mailing Address - Phone:203-371-7111
Mailing Address - Fax:
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:MAIN STREET PEDIATRICS, PC
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-371-7111
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty