1659403855 NPI number — PHYSICIANS SERVICES OF NORTHEAST CT LLC

Table of content: TIMOTHY OWEN JENKINS M.D. (NPI 1558310011)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659403855 NPI number — PHYSICIANS SERVICES OF NORTHEAST CT LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PHYSICIANS SERVICES OF NORTHEAST CT LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1659403855
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 S MAIN ST
Provider Second Line Business Mailing Address:
PO BOX 619
Provider Business Mailing Address City Name:
PUTNAM
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06260-1906
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-963-1077
Provider Business Mailing Address Fax Number:
860-963-1056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 S MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PUTNAM
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06260-1906
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-963-1077
Provider Business Practice Location Address Fax Number:
860-963-1056
Provider Enumeration Date:
03/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TURSKI
Authorized Official First Name:
RENEE
Authorized Official Middle Name:
D
Authorized Official Title or Position:
MEDICARE ADMIN
Authorized Official Telephone Number:
860-963-1077

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  004046512 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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