Basic Information
| Provider Information | |||||||||
| NPI: | 1942735659 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WERNER | ||||||||
| FirstName: | SAMUEL | ||||||||
| MiddleName: | |||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30 JORDAN LN | ||||||||
| Address2: | |||||||||
| City: | WETHERSFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061091278 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602630253 | ||||||||
| FaxNumber: | 8602630262 | ||||||||
| Practice Location | |||||||||
| Address1: | 342 N MAIN ST STE 350 | ||||||||
| Address2: | |||||||||
| City: | WEST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061172500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603313016 | ||||||||
| FaxNumber: | 8603313019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2017 | ||||||||
| LastUpdateDate: | 11/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 204D00000X | 71101 | CT | N | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 204D00000X | 25MB11231200 | NJ | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neuromusculoskeletal Medicine & OMM | 207Q00000X | 25MB11231200 | NJ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | OT017661 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 71101 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.