Provider Demographics
NPI:1124117908
Name:INTERANAL MEDICINE AND PEDIATRIC ASSOCIATES LLC
Entity type:Organization
Organization Name:INTERANAL MEDICINE AND PEDIATRIC ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOYCE
Authorized Official - Middle Name:
Authorized Official - Last Name:FONG-BRETON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-749-2251
Mailing Address - Street 1:15 PALOMBA DR
Mailing Address - Street 2:SUITE 13
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-3888
Mailing Address - Country:US
Mailing Address - Phone:860-749-2251
Mailing Address - Fax:860-745-7747
Practice Address - Street 1:15 PALOMBA DR
Practice Address - Street 2:SUITE 13
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-3888
Practice Address - Country:US
Practice Address - Phone:860-749-2251
Practice Address - Fax:860-745-7747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT=========OtherGROUP TAX ID #
CTC02886Medicare ID - Type UnspecifiedGROUP NUMBER
CK7691Medicare PIN