Provider Demographics
NPI:1255635371
Name:CRESCENT STREET OBSTETRICS & GYNECOLOGY LLC
Entity type:Organization
Organization Name:CRESCENT STREET OBSTETRICS & GYNECOLOGY 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 STREET
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:860-344-9844
Practice Address - Street 1:49 CRESCENT STREET
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:860-344-9844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-04
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025189207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004089729Medicaid
CTC00724Medicare PIN