Provider Demographics
NPI:1093974602
Name:EVERGREEN ENDOSCOPY CENTER, LLC
Entity Type:Organization
Organization Name:EVERGREEN ENDOSCOPY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:WOLLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-533-2123
Mailing Address - Street 1:2400 TAMARACK AVENUE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-644-7336
Mailing Address - Fax:
Practice Address - Street 1:2400 TAMARACK AVENUE
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-644-7336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-09
Last Update Date:2017-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261QE0800XAmbulatory Health Care FacilitiesClinic/CenterEndoscopy