Provider Demographics
NPI:1336494830
Name:PREMIER HEALTHCARE SERVICES OF CONNECTICUT LLC
Entity Type:Organization
Organization Name:PREMIER HEALTHCARE SERVICES OF CONNECTICUT LLC
Other - Org Name:PREMIER URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/ URGENT CARE PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-436-3757
Mailing Address - Street 1:2909 BERLIN TPKE
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-4115
Mailing Address - Country:US
Mailing Address - Phone:860-436-3757
Mailing Address - Fax:860-436-9622
Practice Address - Street 1:2909 BERLIN TPKE
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111-4115
Practice Address - Country:US
Practice Address - Phone:860-436-3757
Practice Address - Fax:860-436-9622
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-20
Last Update Date:2014-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207P00000X, 261QU0200X
CT332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT6742330001Medicare NSC