Provider Demographics
NPI:1376756908
Name:OBGYN GROUP OF EASTERN CONNECTICUT, P.C.
Entity Type:Organization
Organization Name:OBGYN GROUP OF EASTERN CONNECTICUT, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCITELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-1157
Mailing Address - Street 1:2600 TAMARACK AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-5560
Mailing Address - Country:US
Mailing Address - Phone:860-646-1157
Mailing Address - Fax:860-646-9877
Practice Address - Street 1:2600 TAMARACK AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5560
Practice Address - Country:US
Practice Address - Phone:860-646-1157
Practice Address - Fax:860-646-9877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004394251Medicaid
CT004394251Medicaid