Basic Information
| Provider Information | |||||||||
| NPI: | 1023074309 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ELSEMORE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | PT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 57 JUNIPER RIDGE DR | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067081933 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037554563 | ||||||||
| FaxNumber: | 2032649251 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 POMPERAUG OFFICE PARK | ||||||||
| Address2: | SUITE 303 | ||||||||
| City: | SOUTHBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064882288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032641735 | ||||||||
| FaxNumber: | 2032649251 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2006 | ||||||||
| LastUpdateDate: | 10/29/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 007571 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 080007571CT01 | 01 | CT | BLUE SHIELD | OTHER |