Basic Information
| Provider Information | |||||||||
| NPI: | 1891962221 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PHYSICIAN SERVICES OF NORTHEAST | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | SUITE CSB2 | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | SUITE CSB2 | ||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609636450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 09/16/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DROUIN | ||||||||
| AuthorizedOfficialFirstName: | JULIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8609286541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAY KIMBALL HEALTHCARE INC DBA DA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QA0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adolescent Medicine | 207QA0505X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Adult Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 207N00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | 176B00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 008001905 | 05 | CT | MEDICAID | 008014016 | 05 | CT | MEDICAID |