Provider Demographics
NPI:1679605471
Name:LONG WHARF PEDIATRICS & ADOLESCENT MEDICINE LLC
Entity Type:Organization
Organization Name:LONG WHARF PEDIATRICS & ADOLESCENT MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:LUCILLE
Authorized Official - Middle Name:A
Authorized Official - Last Name:SEMERARO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-781-4321
Mailing Address - Street 1:150 SARGENT DR
Mailing Address - Street 2:STE 6
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-6100
Mailing Address - Country:US
Mailing Address - Phone:203-781-4321
Mailing Address - Fax:203-781-4329
Practice Address - Street 1:150 SARGENT DR
Practice Address - Street 2:STE 6
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-6100
Practice Address - Country:US
Practice Address - Phone:203-781-4321
Practice Address - Fax:203-781-4329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherTAX ID NUMBER