Provider Demographics
NPI:1073931648
Name:VIRUET IVELISSE MD INTERNAL MEDICINE LLC
Entity Type:Organization
Organization Name:VIRUET IVELISSE MD INTERNAL MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:IVELISSE
Authorized Official - Middle Name:AUBIN
Authorized Official - Last Name:VIRUET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-432-5803
Mailing Address - Street 1:153 MAIN ST
Mailing Address - Street 2:SUITE 8
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3112
Mailing Address - Country:US
Mailing Address - Phone:860-432-5803
Mailing Address - Fax:860-432-7293
Practice Address - Street 1:153 MAIN ST
Practice Address - Street 2:SUITE 8
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06042-3112
Practice Address - Country:US
Practice Address - Phone:860-432-5803
Practice Address - Fax:860-432-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-01
Last Update Date:2014-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034410207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty