Provider Demographics
NPI:1992969364
Name:STONY CREEK URGENT CARE CENTER, LLC
Entity type:Organization
Organization Name:STONY CREEK URGENT CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:YOUNG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-483-4580
Mailing Address - Street 1:6 BUSINESS PARK DR
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-2988
Mailing Address - Country:US
Mailing Address - Phone:203-483-4580
Mailing Address - Fax:203-483-4581
Practice Address - Street 1:6 BUSINESS PARK DR
Practice Address - Street 2:SUITE 302
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-2988
Practice Address - Country:US
Practice Address - Phone:203-483-4580
Practice Address - Fax:203-483-4581
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STONY CREEK VENTURES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-15
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
D100000134OtherMEDICARE PTAN
CT68WLKN042CT02OtherANTHEMBCBS