Provider Demographics
NPI:1053655548
Name:NUTMEG PEDIATRIC PULMONARY SERVICES LLC
Entity type:Organization
Organization Name:NUTMEG PEDIATRIC PULMONARY SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:REGINA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PALAZZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-208-2395
Mailing Address - Street 1:6 BUSINESS PARK DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2988
Mailing Address - Country:US
Mailing Address - Phone:203-208-2395
Mailing Address - Fax:203-433-4638
Practice Address - Street 1:6 BUSINESS PARK DR
Practice Address - Street 2:SUITE 202
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2988
Practice Address - Country:US
Practice Address - Phone:203-208-2395
Practice Address - Fax:203-433-4638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-21
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0349232080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT034923OtherLICENSE