Provider Demographics
NPI:1073705232
Name:ENFIELD DERMATOLOGY LLC
Entity Type:Organization
Organization Name:ENFIELD DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:SHEEHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-749-7437
Mailing Address - Street 1:146 HAZARD AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4571
Mailing Address - Country:US
Mailing Address - Phone:860-749-7437
Mailing Address - Fax:860-749-0493
Practice Address - Street 1:146 HAZARD AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4571
Practice Address - Country:US
Practice Address - Phone:860-749-7437
Practice Address - Fax:860-749-0493
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-13
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038326207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02917Medicare PIN