Provider Demographics
NPI:1184884355
Name:CRESCENT ST OBGYN LLC
Entity type:Organization
Organization Name:CRESCENT ST OBGYN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIE
Authorized Official - Middle Name:S
Authorized Official - Last Name:FLAGG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-344-9993
Mailing Address - Street 1:49 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3601
Mailing Address - Country:US
Mailing Address - Phone:860-344-9993
Mailing Address - Fax:
Practice Address - Street 1:49 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3601
Practice Address - Country:US
Practice Address - Phone:860-344-9993
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002684363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236924Medicaid
CT004236924Medicaid
CT500001502Medicare PIN