Provider Demographics
NPI:1689894735
Name:INTEGRATED MEDICAL OF NORWALK, LLC
Entity Type:Organization
Organization Name:INTEGRATED MEDICAL OF NORWALK, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:LANCE
Authorized Official - Last Name:GERSTENFELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-845-0400
Mailing Address - Street 1:365 WESTPORT AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CT
Mailing Address - Zip Code:06851-4344
Mailing Address - Country:US
Mailing Address - Phone:203-845-0400
Mailing Address - Fax:203-845-0005
Practice Address - Street 1:365 WESTPORT AVE
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06851-4344
Practice Address - Country:US
Practice Address - Phone:203-845-0400
Practice Address - Fax:203-845-0005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031959261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTF36301Medicare UPIN