Provider Demographics
NPI:1427240910
Name:FAMILY MEDICINE CENTER,LLC
Entity type:Organization
Organization Name:FAMILY MEDICINE CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:MACLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-4060
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-0112
Mailing Address - Country:US
Mailing Address - Phone:860-646-4334
Mailing Address - Fax:
Practice Address - Street 1:574 E MIDDLE TPKE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-646-4334
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-17
Last Update Date:2008-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTDA5952OtherRAILROAD MEDICARE
DA5952Medicare PIN
CTC02981Medicare PIN