1689873887 NPI number — EASTERN CONNECTICUT FOOT SPECIALISTS, P. C.

Table of content: (NPI 1689873887)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689873887 NPI number — EASTERN CONNECTICUT FOOT SPECIALISTS, P. C.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN CONNECTICUT FOOT SPECIALISTS, P. C.
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:
1689873887
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/17/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11 WAWECUS ST STE 2
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:
06360-2121
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-887-3538
Provider Business Mailing Address Fax Number:
860-887-1394

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11 WAWECUS ST STE 2
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:
06360-2121
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-887-3538
Provider Business Practice Location Address Fax Number:
860-887-1394
Provider Enumeration Date:
07/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TARKA
Authorized Official First Name:
EDWARD
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
860-887-3538

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  000570 , 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: CE0564 . This is a "RAIL ROAD MEDICARE GROUP PTAN" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".




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