Provider Demographics
NPI:1174792949
Name:NUTMEG PEDIATRIC PULMONARY SERVICES
Entity type:Organization
Organization Name:NUTMEG PEDIATRIC PULMONARY SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
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:203-789-1338
Mailing Address - Street 1:60 TEMPLE ST
Mailing Address - Street 2:7F
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510
Mailing Address - Country:US
Mailing Address - Phone:203-789-1338
Mailing Address - Fax:203-789-1478
Practice Address - Street 1:60 TEMPLE ST
Practice Address - Street 2:7F
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510
Practice Address - Country:US
Practice Address - Phone:203-789-1338
Practice Address - Fax:203-789-1478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001349233Medicaid
CTE57998Medicare UPIN
CT370001562Medicare PIN
CTC03229Medicare PIN