Provider Demographics
NPI:1801055819
Name:SUSAN KAMOVITCH
Entity type:Organization
Organization Name:SUSAN KAMOVITCH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KAMOVITCH
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-255-3367
Mailing Address - Street 1:206 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-6322
Mailing Address - Country:US
Mailing Address - Phone:203-255-3367
Mailing Address - Fax:
Practice Address - Street 1:206 SOUTH ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6322
Practice Address - Country:US
Practice Address - Phone:203-255-3367
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-04
Last Update Date:2008-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500002352Medicare PIN