Provider Demographics
NPI:1760563746
Name:MEDICAL SPECIALISTS OF FAIRFIELD, LLC
Entity Type:Organization
Organization Name:MEDICAL SPECIALISTS OF FAIRFIELD, LLC
Other - Org Name:
Other - Org Type:
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 1:425 POST RD
Practice Address - Street 2:SOUTH LOBBY
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6232
Practice Address - Country:US
Practice Address - Phone:203-255-4545
Practice Address - Fax:203-254-1191
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
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
CTC00444Medicare ID - Type Unspecified
CT0817870001Medicare NSC