Provider Demographics
NPI:1508375064
Name:CIVIC WILTON, PLLC
Entity Type:Organization
Organization Name:CIVIC WILTON, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:M
Authorized Official - Last Name:ROTEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:816-537-3433
Mailing Address - Street 1:249 DANBURY RD
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:CT
Mailing Address - Zip Code:06897-4070
Mailing Address - Country:US
Mailing Address - Phone:816-537-3431
Mailing Address - Fax:816-537-3431
Practice Address - Street 1:249 DANBURY ROAD
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:CT
Practice Address - Zip Code:06897
Practice Address - Country:US
Practice Address - Phone:816-537-3433
Practice Address - Fax:816-537-3431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-27
Last Update Date:2022-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039079207LP2900X
261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Single Specialty