Provider Demographics
NPI:1164443990
Name:LEDGEBROOK FAMILY PRACTICE, LLC
Entity Type:Organization
Organization Name:LEDGEBROOK FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:JAWORSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-456-1485
Mailing Address - Street 1:6 LEDGEBROOK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MANSFIELD CENTER
Mailing Address - State:CT
Mailing Address - Zip Code:06250-1644
Mailing Address - Country:US
Mailing Address - Phone:860-456-1485
Mailing Address - Fax:860-423-1589
Practice Address - Street 1:6 LEDGEBROOK DR
Practice Address - Street 2:SUITE A
Practice Address - City:MANSFIELD CENTER
Practice Address - State:CT
Practice Address - Zip Code:06250-1644
Practice Address - Country:US
Practice Address - Phone:860-456-1485
Practice Address - Fax:860-423-1589
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty