Basic Information
| Provider Information | |||||||||
| NPI: | 1629461116 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | URGENT CARE OF DERBY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIANONE URGENT CARE- DERBY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2928 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | GLASTONBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060331007 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606578289 | ||||||||
| FaxNumber: | 8606578291 | ||||||||
| Practice Location | |||||||||
| Address1: | 78 PERSHING DR | ||||||||
| Address2: | |||||||||
| City: | DERBY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064181433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035165307 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2015 | ||||||||
| LastUpdateDate: | 03/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | KENKARE | ||||||||
| AuthorizedOfficialFirstName: | JEANNIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF MEDICAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8606578289 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 008056635 | 05 | CT | MEDICAID | 008049246 | 05 | CT | MEDICAID | 008049245 | 05 | CT | MEDICAID | 008049195 | 05 | CT | MEDICAID |