Organization
ESSEX DERMATOLOGY LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. VIRGINIA L MAHER WIESE MD (OWNER)
(860) 767-9998
Entity
Organization
Contact information
Practice address
20 SAYBROOK ROAD, ESSEX, CT 06426-1401
(860) 767-9998
(860) 767-9161
Mailing address
20 SAYBROOK ROAD, ESSEX, CT 06426-1401
(860) 767-9998
(860) 767-9161
Taxonomy
Speciality
Code
Description
License number
State
207N00000X
Dermatology Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
C03091
MEDICARE ID - GROUP
CT
Enumeration date
12/05/2006
Last updated
11/15/2012
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