Provider Demographics
NPI:1790800480
Name:CRV DERMATOLOGY LLC
Entity Type:Organization
Organization Name:CRV DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLENE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:HAVILAND
Authorized Official - Suffix:
Authorized Official - Credentials:PAC
Authorized Official - Phone:860-741-2225
Mailing Address - Street 1:113 ELM ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3700
Mailing Address - Country:US
Mailing Address - Phone:860-741-2225
Mailing Address - Fax:860-741-2229
Practice Address - Street 1:113 ELM ST
Practice Address - Street 2:SUITE 200
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3700
Practice Address - Country:US
Practice Address - Phone:860-741-2225
Practice Address - Fax:860-741-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001494363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT2051095Medicaid
CT9748130Medicaid
CT2051095Medicaid
CTC03513Medicare ID - Type UnspecifiedGROUP NUMBER
CTS17713Medicare UPIN