Provider Demographics
NPI:1992132161
Name:FAMILY MEDICINE PARTERSHIP
Entity type:Organization
Organization Name:FAMILY MEDICINE PARTERSHIP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BUCKMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-646-0649
Mailing Address - Street 1:921 BOSTON TPKE
Mailing Address - Street 2:STE A
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-7403
Mailing Address - Country:US
Mailing Address - Phone:860-646-0649
Mailing Address - Fax:860-649-1995
Practice Address - Street 1:921 BOSTON TPKE
Practice Address - Street 2:STE A
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043-7403
Practice Address - Country:US
Practice Address - Phone:860-646-0649
Practice Address - Fax:860-649-1995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-03
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5515363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004199825Medicaid
CT0308497007OtherCONNECTICARE