Provider Demographics
NPI:1700864097
Name:MEDICAL SPECIALISTS OF FAIRFIELD, LLC
Entity Type:Organization
Organization Name:MEDICAL SPECIALISTS OF FAIRFIELD, LLC
Other - Org Name:SWIM HEMATOLOGY ONCOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GLEN
Authorized Official - Middle Name:
Authorized Official - Last Name:REZNIKOFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-255-4545
Mailing Address - Street 1:425 POST RD
Mailing Address - Street 2:SOUTH LOBBY
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6232
Mailing Address - Country:US
Mailing Address - Phone:203-255-4545
Mailing Address - Fax:203-254-1191
Practice Address - Street 1:2800 MAIN ST
Practice Address - Street 2:3RD FLR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-4201
Practice Address - Country:US
Practice Address - Phone:203-382-2475
Practice Address - Fax:203-382-2488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010013862CT01OtherBCBS CT
CT004082666Medicaid
CT104363800OtherDEPT OF LABOR
NYS2G58OtherBCBS NY
CT104363800OtherDEPT OF LABOR