Provider Demographics
NPI:1245410406
Name:INTERNAL MEDICINE SPECIALISTS
Entity Type:Organization
Organization Name:INTERNAL MEDICINE SPECIALISTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:A
Authorized Official - Last Name:REILLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-597-0393
Mailing Address - Street 1:1389 WEST MAIN ST
Mailing Address - Street 2:STE 224
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-0000
Mailing Address - Country:US
Mailing Address - Phone:203-597-0393
Mailing Address - Fax:
Practice Address - Street 1:1389 W MAIN ST
Practice Address - Street 2:STE 224
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-3104
Practice Address - Country:US
Practice Address - Phone:203-597-0393
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2015-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT19477207R00000X, 207RE0101X
CT003751363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty