Basic Information
| Provider Information | |||||||||
| NPI: | 1558473769 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KUCHARCHIK | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 635 MAIN ST | ||||||||
| Address2: | ATTN: CREDENTIALING DPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | 8606386601 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 GOLD STAR HWY | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | GROTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 063406702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604468858 | ||||||||
| FaxNumber: | 8604052140 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/01/2006 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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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 | 207Q00000X | 25896 | CT | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 9785 | SC | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 097852 | 05 | SC | MEDICAID | 761101 | 01 | CONNECTICARE | OTHER | 030897 | 01 | CT | HEALTHNET | OTHER | NLP057 | 01 | CT | OXFORD | OTHER | SC11353402 | 01 | SC | MEDICARE PTAN | OTHER | 001258961 | 05 | CT | MEDICAID | 010025896CT01 | 01 | BCBS | OTHER |