Provider Demographics
NPI:1629461116
Name:URGENT CARE OF DERBY, LLC
Entity Type:Organization
Organization Name:URGENT CARE OF DERBY, LLC
Other - Org Name:PHYSICIANONE URGENT CARE- DERBY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JEANNIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:KENKARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-657-8289
Mailing Address - Street 1:2928 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06033-1007
Mailing Address - Country:US
Mailing Address - Phone:860-657-8289
Mailing Address - Fax:860-657-8291
Practice Address - Street 1:78 PERSHING DR
Practice Address - Street 2:
Practice Address - City:DERBY
Practice Address - State:CT
Practice Address - Zip Code:06418-1433
Practice Address - Country:US
Practice Address - Phone:203-516-5307
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-03-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008056635Medicaid
CT008049246Medicaid
CT008049245Medicaid
CT008049195Medicaid
CT008049245Medicaid