Provider Demographics
NPI:1275801771
Name:PHYSICIAN SERVICES OF NORTHEAST
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES OF NORTHEAST
Other - Org Name:PHYSICIAN SERVICES OF NORTHEAST CT, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DROUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-928-6541
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:SUITE CSB2
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-928-6541
Practice Address - Fax:860-963-6450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAY KIMBALL HOSPITAL OF WINDHAM COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-12-12
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100000012Medicare PIN