Provider Demographics
NPI:1255371571
Name:FAMILY PRACTICE & INTERNAL MEDICINE OF SPRING GREN LLC
Entity type:Organization
Organization Name:FAMILY PRACTICE & INTERNAL MEDICINE OF SPRING GREN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PETEUZZIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-407-6410
Mailing Address - Street 1:2200 WHITHEY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMDEH
Mailing Address - State:CT
Mailing Address - Zip Code:06518
Mailing Address - Country:US
Mailing Address - Phone:203-407-6410
Mailing Address - Fax:203-407-6433
Practice Address - Street 1:2200 WHITHEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMDEH
Practice Address - State:CT
Practice Address - Zip Code:06518
Practice Address - Country:US
Practice Address - Phone:203-407-6410
Practice Address - Fax:203-407-6433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CG7487OtherRRM
CG7487OtherRRM