Provider Demographics
NPI:1922230200
Name:WINDSOR PARK FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:WINDSOR PARK FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HYOUNGSUP
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-288-2750
Mailing Address - Street 1:85 FELT ROAD
Mailing Address - Street 2:SUITE 501
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-228-2750
Mailing Address - Fax:860-783-5460
Practice Address - Street 1:85 FELT ROAD
Practice Address - Street 2:SUITE 501
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-228-2750
Practice Address - Fax:860-783-5460
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-20
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043254207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty