Basic Information
Provider Information | |||||||||
NPI: | 1093292310 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PHYSICIANS ALLIANCE OF CONNECTICUT, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 322 E MAIN ST STE 1B | ||||||||
Address2: |   | ||||||||
City: | BRANFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 064053136 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034887228 | ||||||||
FaxNumber: | 2034887227 | ||||||||
Practice Location | |||||||||
Address1: | 350 GOOSE LN STE 203B | ||||||||
Address2: |   | ||||||||
City: | GUILFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 064372158 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2034082700 | ||||||||
FaxNumber: | 2038848201 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/20/2018 | ||||||||
LastUpdateDate: | 06/24/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BARCHAT | ||||||||
AuthorizedOfficialFirstName: | YVETTE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | COO | ||||||||
AuthorizedOfficialTelephone: | 2034887228 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | PHYSICIANS ALLIANCE OF CONNECTICUT, LLC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XS0106X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Hand Surgery | 332B00000X |   |   | N |   | Suppliers | Durable Medical Equipment & Medical Supplies |   | 207X00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.