Provider Demographics
NPI:1194966556
Name:PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC
Entity type:Organization
Organization Name:PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:SMANIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-928-6541
Mailing Address - Street 1:PO BOX 8469
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-8469
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:235 POMFRET ST
Practice Address - Street 2:
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1835
Practice Address - Country:US
Practice Address - Phone:860-928-0493
Practice Address - Fax:860-928-9255
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAY KIMBALL HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-16
Last Update Date:2009-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1891962221Medicaid
CT1891962221Medicaid