Basic Information
| Provider Information | |||||||||
| NPI: | 1669603767 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN SERVICES OF NORTHEAST | ||||||||
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| OtherOrganizationName: | PHYSICIAN SERVICES OF NORTHEAST CT, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | SUITE CSB#2 | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636091 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | SUITE, CSB2 | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636091 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2009 | ||||||||
| LastUpdateDate: | 12/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | DROUIN | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8609286541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAY KIMBALL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.