Basic Information
| Provider Information | |||||||||
| NPI: | 1982889598 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST EMERGENCY MEDICINE SPECIALISTS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6896 W SNOWVILLE RD | ||||||||
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| City: | BRECKSVILLE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 441413214 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
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| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002610048 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2008 | ||||||||
| LastUpdateDate: | 11/06/2009 | ||||||||
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| AuthorizedOfficialLastName: | WINCHESTER | ||||||||
| AuthorizedOfficialFirstName: | EUGENE | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 8002610048 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500HBE466CT01 | 01 | CT | ANTHEM BCBS | OTHER |