Provider Demographics
NPI:1437359759
Name:PHILIP A MICALIZZI, JR. M.D. PC
Entity Type:Organization
Organization Name:PHILIP A MICALIZZI, JR. M.D. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:A
Authorized Official - Last Name:MICALIZZI
Authorized Official - Suffix:II
Authorized Official - Credentials:MD
Authorized Official - Phone:203-372-6505
Mailing Address - Street 1:3180 MAIN STREET
Mailing Address - Street 2:STE 302
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606
Mailing Address - Country:US
Mailing Address - Phone:203-372-6505
Mailing Address - Fax:203-372-5622
Practice Address - Street 1:3180 MAIN ST
Practice Address - Street 2:STE 302
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4237
Practice Address - Country:US
Practice Address - Phone:203-372-6505
Practice Address - Fax:203-372-5622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-24
Last Update Date:2007-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT026207305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD02732Medicare UPIN