Provider Demographics
NPI:1326265745
Name:EAST LYME PEDIATRIC CLINIC, LLC
Entity Type:Organization
Organization Name:EAST LYME PEDIATRIC CLINIC, LLC
Other - Org Name:EAST LYME PEDIATRIC CLINIC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:SAJDA
Authorized Official - Middle Name:PERWEEN
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-739-7444
Mailing Address - Street 1:170 FLANDERS RD
Mailing Address - Street 2:
Mailing Address - City:NIANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06357-1208
Mailing Address - Country:US
Mailing Address - Phone:860-739-7444
Mailing Address - Fax:860-739-3252
Practice Address - Street 1:170 FLANDERS RD
Practice Address - Street 2:
Practice Address - City:NIANTIC
Practice Address - State:CT
Practice Address - Zip Code:06357-1208
Practice Address - Country:US
Practice Address - Phone:860-739-7444
Practice Address - Fax:860-739-3252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-19
Last Update Date:2013-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT27074261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001365263Medicaid
CT001365263Medicaid