Provider Demographics
NPI:1760537013
Name:WEST SIDE MEDICAL CENTER, LLC
Entity Type:Organization
Organization Name:WEST SIDE MEDICAL CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:H
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:860-889-1400
Mailing Address - Street 1:606 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-6007
Mailing Address - Country:US
Mailing Address - Phone:860-889-1400
Mailing Address - Fax:860-889-3163
Practice Address - Street 1:606 W MAIN ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-6007
Practice Address - Country:US
Practice Address - Phone:860-889-1400
Practice Address - Fax:860-889-3163
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-25
Last Update Date:2013-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X207Q00000X
CT005383363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4504270001Medicare NSC
CTD100000047Medicare PIN