Provider Demographics
NPI:1902095003
Name:FAMILY PRACTICE & INTERNAL MEDICINE, LLC
Entity Type:Organization
Organization Name:FAMILY PRACTICE & INTERNAL MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRUZZIELLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-672-2800
Mailing Address - Street 1:52 WASHINGTON AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-1724
Mailing Address - Country:US
Mailing Address - Phone:203-672-2800
Mailing Address - Fax:203-672-2801
Practice Address - Street 1:52 WASHINGTON AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-1724
Practice Address - Country:US
Practice Address - Phone:203-672-2800
Practice Address - Fax:203-672-2801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-15
Last Update Date:2012-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500000049Medicaid
CTDG5581OtherRAILROAD MEDICARE
CTDG5581OtherRAILROAD MEDICARE
CTC03810Medicare PIN