Provider Demographics
NPI:1194915314
Name:MEDICAL CENTER OF NORTHEAST CONNECTICUT
Entity type:Organization
Organization Name:MEDICAL CENTER OF NORTHEAST CONNECTICUT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MATTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-779-0284
Mailing Address - Street 1:612 HARTFORD PIKE
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-2159
Mailing Address - Country:US
Mailing Address - Phone:860-779-0284
Mailing Address - Fax:860-779-0386
Practice Address - Street 1:612 HARTFORD PIKE
Practice Address - Street 2:
Practice Address - City:DAYVILLE
Practice Address - State:CT
Practice Address - Zip Code:06241-2159
Practice Address - Country:US
Practice Address - Phone:860-779-0284
Practice Address - Fax:860-779-0386
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-25
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001172865Medicaid
CT001367178Medicaid
CT001292490Medicaid
CT001413476Medicaid
CT001228592Medicaid
CT001295006Medicaid
CTC00434Medicare PIN
CT001228592Medicaid
CTB39169Medicare UPIN
CTB39660Medicare UPIN
CTB98139Medicare UPIN
CT001292490Medicaid
CT001172865Medicaid