Provider Demographics
NPI:1710052725
Name:NORTHWEST PHYSICAL MEDICINE. LLC
Entity Type:Organization
Organization Name:NORTHWEST PHYSICAL MEDICINE. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:R
Authorized Official - Last Name:CARBON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:860-496-0333
Mailing Address - Street 1:1185 NEW LITCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6017
Mailing Address - Country:US
Mailing Address - Phone:860-496-0333
Mailing Address - Fax:860-496-0333
Practice Address - Street 1:1185 NEW LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6017
Practice Address - Country:US
Practice Address - Phone:860-496-0333
Practice Address - Fax:860-496-0948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040327208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G79772Medicare UPIN