1811191216 NPI number — EASTERN CONNECTICUT PAIN TREATMENT CENTER LLC

Table of content: (NPI 1811191216)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811191216 NPI number — EASTERN CONNECTICUT PAIN TREATMENT CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN CONNECTICUT PAIN TREATMENT CENTER 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:
1811191216
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
190 W TOWN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWICH
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06360-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-885-0333
Provider Business Mailing Address Fax Number:
860-885-1319

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 W TOWN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORWICH
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06360-2131
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-885-0333
Provider Business Practice Location Address Fax Number:
860-885-1319
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
PAGGIOLI
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MD
Authorized Official Telephone Number:
860-885-0333

Provider Taxonomy Codes

  • Taxonomy code: 207LP2900X , with the licence number:  035017 , 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)

  • Identifier: 2V8671 . This is a "HEALTHNET OF THE NORTHEAST" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 7135534005 . This is a "CIGNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: P2176298 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 001350173 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5588518 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 035017 . This is a "CONNECTICARE" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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