NPIMap

Organization Active NPI

CRV Dermatology LLC

  • Physician Assistant
  • Enfield, CT
National Provider Identifier
1790800480
Registry record updated Aug 22, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
001494 Issued in CT
Legal business name
CRV DERMATOLOGY LLC
Practice address
113 Elm St
Suite 200
Enfield, CT 06082-3700
Phone
(860) 741-2225
Fax
(860) 741-2229
NPI assigned
Mar 20, 2007
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Aug 22, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Ms. Darlene Marie Haviland, PACNPI 1720067879
Title
President Owner
Phone
(860) 741-2225

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician AssistantGroup: 193400000X SINGLE SPECIALTY GROUP 363A00000X 001494 CT Primary

Addresses

Primary practice location

113 Elm St
Suite 200
Enfield, CT 06082-3700

Mailing address

113 Elm St
Suite 200
Enfield, CT 06082-3700
Phone (860) 741-2225

Other identifiers 2

IdentifierTypeStateIssuer
2051095MedicaidCT
9748130MedicaidCT

National Provider Directory

National Provider Directory

Locations

113 Elm St
Ste 200
Enfield, CT 06082
Phone (860) 741-2225

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1174348800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1790800480",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "113 ELM ST",
            "address_2": "SUITE 200",
            "city": "ENFIELD",
            "state": "CT",
            "postal_code": "060823700",
            "telephone_number": "860-741-2225",
            "fax_number": "860-741-2229"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "113 ELM ST",
            "address_2": "SUITE 200",
            "city": "ENFIELD",
            "state": "CT",
            "postal_code": "060823700",
            "telephone_number": "860-741-2225",
            "fax_number": "860-741-2229"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "CRV DERMATOLOGY LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-03-20",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "HAVILAND",
        "authorized_official_first_name": "DARLENE",
        "authorized_official_middle_name": "MARIE",
        "authorized_official_title_or_position": "PRESIDENT OWNER",
        "authorized_official_telephone_number": "860-741-2225",
        "authorized_official_name_prefix": "Ms.",
        "authorized_official_credential": "PAC"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Physician Assistant",
            "state": "CT",
            "license": "001494",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2051095",
            "state": "CT"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "9748130",
            "state": "CT"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Enfield, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.