Provider Demographics
NPI:1497864516
Name:EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION, INC
Entity Type:Organization
Organization Name:EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION, INC
Other - Org Name:EASTERN ORTHOPEADICS AND SPORTS MEDICINE, PC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:R
Authorized Official - Last Name:ALLEYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-648-4480
Mailing Address - Street 1:2800 TAMARACK AVENUE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-648-4480
Mailing Address - Fax:860-648-2132
Practice Address - Street 1:2800 TAMARACK AVENUE
Practice Address - Street 2:SUITE 104
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-648-4480
Practice Address - Fax:860-648-2132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5926570001Medicare NSC