Provider Demographics
NPI:1063472363
Name:EAST HADDAM MEDICAL ASSOCIATE,PC
Entity Type:Organization
Organization Name:EAST HADDAM MEDICAL ASSOCIATE,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOURLIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-873-8983
Mailing Address - Street 1:16 WILLIAM F PALMER RD
Mailing Address - Street 2:P O BOX 430
Mailing Address - City:MOODUS
Mailing Address - State:CT
Mailing Address - Zip Code:06469-1131
Mailing Address - Country:US
Mailing Address - Phone:860-873-1414
Mailing Address - Fax:860-873-3428
Practice Address - Street 1:16 WILLIAM F PALMER RD
Practice Address - Street 2:
Practice Address - City:MOODUS
Practice Address - State:CT
Practice Address - Zip Code:06469-1131
Practice Address - Country:US
Practice Address - Phone:860-873-1414
Practice Address - Fax:860-873-3428
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024845207Q00000X
CT000457363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Not Answered363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
=========OtherTIN
C01058Medicare ID - Type Unspecified