Provider Demographics
NPI:1619181500
Name:TOLLAND COUNTY PEDIATRICS & ADOLESCENT MEDICINE, LLC
Entity Type:Organization
Organization Name:TOLLAND COUNTY PEDIATRICS & ADOLESCENT MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:H
Authorized Official - Last Name:SENECHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-875-9856
Mailing Address - Street 1:239 MERROW RD
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3915
Mailing Address - Country:US
Mailing Address - Phone:860-875-9856
Mailing Address - Fax:860-875-9868
Practice Address - Street 1:239 MERROW RD
Practice Address - Street 2:
Practice Address - City:TOLLAND
Practice Address - State:CT
Practice Address - Zip Code:06084-3915
Practice Address - Country:US
Practice Address - Phone:860-875-9856
Practice Address - Fax:860-875-9868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-09
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004252128Medicaid
2080A0000XOtherTAXONOMY NUMBER