Provider Demographics
NPI:1932141298
Name:EASTERN CONNECTICUT NEUROLOGY SPECIALIST LLC
Entity Type:Organization
Organization Name:EASTERN CONNECTICUT NEUROLOGY SPECIALIST LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOODRUFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-647-9183
Mailing Address - Street 1:PO BOX 3262
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-2162
Mailing Address - Country:US
Mailing Address - Phone:860-896-1422
Mailing Address - Fax:860-896-1425
Practice Address - Street 1:394 W CENTER ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4735
Practice Address - Country:US
Practice Address - Phone:860-647-9183
Practice Address - Fax:860-647-0582
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2014-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0395842084N0400X
CT005619363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03446OtherMEDICARE GROUP
CTC03446OtherMEDICARE GROUP
CT=========OtherTAX ID