Provider Demographics
NPI:1902909708
Name:SAYBROOK DERMATOLOGY LLC
Entity Type:Organization
Organization Name:SAYBROOK DERMATOLOGY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:LARSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-388-9799
Mailing Address - Street 1:455 BOSTON POST RD STE 10
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-1554
Mailing Address - Country:US
Mailing Address - Phone:860-388-9799
Mailing Address - Fax:860-388-6646
Practice Address - Street 1:455 BOSTON POST RD STE 10
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-1554
Practice Address - Country:US
Practice Address - Phone:860-388-9799
Practice Address - Fax:860-388-6646
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2020-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C02937Medicare ID - Type Unspecified
H17781Medicare UPIN
H77669Medicare UPIN