Provider Demographics
NPI:1447201793
Name:EASTERN CONNECTICUT HEART ASSOCIATES
Entity Type:Organization
Organization Name:EASTERN CONNECTICUT HEART ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:
Authorized Official - Last Name:FISHERKELLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-688-0033
Mailing Address - Street 1:PO BOX 112
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06095-0112
Mailing Address - Country:US
Mailing Address - Phone:860-688-0033
Mailing Address - Fax:
Practice Address - Street 1:112 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2041
Practice Address - Country:US
Practice Address - Phone:860-456-2898
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2007-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02373Medicare PIN