Provider Demographics
NPI:1346543642
Name:POURKAVOOS MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:POURKAVOOS MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KHOSRO
Authorized Official - Middle Name:
Authorized Official - Last Name:POURKAVOOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-676-0090
Mailing Address - Street 1:35 NOD RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3826
Mailing Address - Country:US
Mailing Address - Phone:860-676-0090
Mailing Address - Fax:860-676-0040
Practice Address - Street 1:35 NOD RD
Practice Address - Street 2:SUITE 205
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3826
Practice Address - Country:US
Practice Address - Phone:860-676-0090
Practice Address - Fax:860-676-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-09
Last Update Date:2010-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001397092Medicaid
CTF 30245Medicare PIN