Provider Demographics
NPI:1548211188
Name:EASTERN CT CARDIOLOGY DIAGNOSTICS, LLC
Entity Type:Organization
Organization Name:EASTERN CT CARDIOLOGY DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:S
Authorized Official - Last Name:EHRLICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-443-4383
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 103
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-443-4383
Mailing Address - Fax:860-443-3980
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 103
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-443-4383
Practice Address - Fax:860-443-3980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-15
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CH9157OtherRR MEDICARE
CT004217130Medicaid
CH9157OtherRR MEDICARE
=========OtherTRICARE
CT004217130Medicaid
C02785Medicare ID - Type Unspecified