Provider Demographics
NPI:1215164058
Name:SOUTHERN NEW ENGLAND EAR, NOSE, THROAT AND FACIAL PLASTIC SURGERY GROU
Entity type:Organization
Organization Name:SOUTHERN NEW ENGLAND EAR, NOSE, THROAT AND FACIAL PLASTIC SURGERY GROU
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:EIIZABETH
Authorized Official - Middle Name:IRENE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-777-7500
Mailing Address - Street 1:ONE LONG WHARF DRIVE
Mailing Address - Street 2:SUITE #302
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-5593
Mailing Address - Country:US
Mailing Address - Phone:203-777-7500
Mailing Address - Fax:203-777-8469
Practice Address - Street 1:ONE LONG WHARF DRIVE
Practice Address - Street 2:SUITE #302
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-5593
Practice Address - Country:US
Practice Address - Phone:203-777-7500
Practice Address - Fax:203-777-8469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-19
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034314174400000X
207YX0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207YX0905XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngology/Facial Plastic SurgeryGroup - Single Specialty
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty