Provider Demographics
NPI:1528473519
Name:STAMFORD PHYSICAL MEDICINE PC
Entity type:Organization
Organization Name:STAMFORD PHYSICAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:INGLIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-325-0174
Mailing Address - Street 1:90 MORGAN ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5466
Mailing Address - Country:US
Mailing Address - Phone:203-325-0174
Mailing Address - Fax:203-325-3551
Practice Address - Street 1:90 MORGAN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5466
Practice Address - Country:US
Practice Address - Phone:203-325-0174
Practice Address - Fax:203-325-3551
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-27
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT033974208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TND100187317Medicare PIN