Basic Information
| Provider Information | |||||||||
| NPI: | 1841437456 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BROOKLYN FAMILY MEDICINE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 8469 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049158469 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Practice Location | |||||||||
| Address1: | 63 CANTERBURY RD | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062341901 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8607795940 | ||||||||
| FaxNumber: | 8607795499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/20/2009 | ||||||||
| LastUpdateDate: | 01/20/2009 | ||||||||
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| AuthorizedOfficialLastName: | SMANIK | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8609286541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAY KIMBALL HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1891962221 | 05 | CT | MEDICAID |