Provider Demographics
NPI:1245372176
Name:GALES FERRY PEDIATRIC GROUP
Entity type:Organization
Organization Name:GALES FERRY PEDIATRIC GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:ROBERT
Authorized Official - Last Name:ESPOSITO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-464-7248
Mailing Address - Street 1:1527 ROUTE 12
Mailing Address - Street 2:PO BOX 608
Mailing Address - City:GALES FERRY
Mailing Address - State:CT
Mailing Address - Zip Code:06335-0608
Mailing Address - Country:US
Mailing Address - Phone:860-464-7248
Mailing Address - Fax:860-464-0125
Practice Address - Street 1:1527 ROUTE 12
Practice Address - Street 2:
Practice Address - City:GALES FERRY
Practice Address - State:CT
Practice Address - Zip Code:06335-1800
Practice Address - Country:US
Practice Address - Phone:860-464-7248
Practice Address - Fax:860-464-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-14
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty