Provider Demographics
NPI:1790791481
Name:NEW HAVEN MEDICAL SPORTS & OCCUPATIONAL HEALTH
Entity Type:Organization
Organization Name:NEW HAVEN MEDICAL SPORTS & OCCUPATIONAL HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:PISERCHIA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-776-3375
Mailing Address - Street 1:1213 CHAPEL ST
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4701
Mailing Address - Country:US
Mailing Address - Phone:203-776-3375
Mailing Address - Fax:203-776-3171
Practice Address - Street 1:1213 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4701
Practice Address - Country:US
Practice Address - Phone:203-776-3375
Practice Address - Fax:203-776-3171
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-01
Last Update Date:2014-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001097111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02611Medicare PIN