Provider Demographics
NPI:1730497751
Name:CONNECTICUT DERMATOLOGY LLC
Entity Type:Organization
Organization Name:CONNECTICUT DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALANE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-272-3376
Mailing Address - Street 1:1781 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-1254
Mailing Address - Country:US
Mailing Address - Phone:203-272-3376
Mailing Address - Fax:203-272-9539
Practice Address - Street 1:1781 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:CHESHIRE
Practice Address - State:CT
Practice Address - Zip Code:06410-1254
Practice Address - Country:US
Practice Address - Phone:203-272-3376
Practice Address - Fax:203-272-9539
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-24
Last Update Date:2010-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTG38502Medicare UPIN