1629461116 NPI number — URGENT CARE OF DERBY, LLC

Table of content: (NPI 1629461116)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629461116 NPI number — URGENT CARE OF DERBY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
URGENT CARE OF DERBY, 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:
PHYSICIANONE URGENT CARE- DERBY
Provider Other Organization Name Type Code:
3
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:
1629461116
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2928 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GLASTONBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06033-1007
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-657-8289
Provider Business Mailing Address Fax Number:
860-657-8291

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
78 PERSHING DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERBY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06418-1433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-516-5307
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/09/2015

Additional Information

Authorized Official

Authorized Official Last Name:
KENKARE
Authorized Official First Name:
JEANNIE
Authorized Official Middle Name:
M
Authorized Official Title or Position:
CHIEF MEDICAL OFFICER
Authorized Official Telephone Number:
860-657-8289

Provider Taxonomy Codes

  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 008056635 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008049246 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008049245 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008049195 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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