Provider Demographics
NPI:1942669916
Name:PEDIATRIC ADVANCED CARE OF WEST HAVEN LLC
Entity type:Organization
Organization Name:PEDIATRIC ADVANCED CARE OF WEST HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:J
Authorized Official - Last Name:MARCUCIO
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-889-2297
Mailing Address - Street 1:24 N COE LN
Mailing Address - Street 2:
Mailing Address - City:ANSONIA
Mailing Address - State:CT
Mailing Address - Zip Code:06401-2818
Mailing Address - Country:US
Mailing Address - Phone:203-732-1662
Mailing Address - Fax:
Practice Address - Street 1:755 CAMPBELL AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-3715
Practice Address - Country:US
Practice Address - Phone:203-889-2297
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-18
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004531363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty