Provider Demographics
NPI:1891962221
Name:PHYSICIAN SERVICES OF NORTHEAST
Entity Type:Organization
Organization Name:PHYSICIAN SERVICES OF NORTHEAST
Other - Org Name:PHYSICIAN SERVICES OF NORTHEAST CONNECTICUT, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:
Authorized Official - Last Name:DROUIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-928-6541
Mailing Address - Street 1:320 POMFRET ST
Mailing Address - Street 2:SUITE CSB2
Mailing Address - City:PUTNAM
Mailing Address - State:CT
Mailing Address - Zip Code:06260-1836
Mailing Address - Country:US
Mailing Address - Phone:860-928-6541
Mailing Address - Fax:860-963-6450
Practice Address - Street 1:320 POMFRET ST
Practice Address - Street 2:SUITE CSB2
Practice Address - City:PUTNAM
Practice Address - State:CT
Practice Address - Zip Code:06260-1836
Practice Address - Country:US
Practice Address - Phone:860-928-6541
Practice Address - Fax:860-963-6450
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DAY KIMBALL HEALTHCARE INC DBA DA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-14
Last Update Date:2011-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT176B00000X
207N00000X, 207Q00000X, 207QA0000X, 207QA0505X, 207R00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No176B00000XOther Service ProvidersMidwifeGroup - Multi-Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207QA0000XAllopathic & Osteopathic PhysiciansFamily MedicineAdolescent MedicineGroup - Multi-Specialty
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008001905Medicaid
CT008014016Medicaid
CT008014016Medicaid