Provider Demographics
NPI:1396916912
Name:SOMERS FAMILY PRACTICE, LLC
Entity type:Organization
Organization Name:SOMERS FAMILY PRACTICE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:STERLING
Authorized Official - Last Name:TUCKER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-749-8887
Mailing Address - Street 1:P.O. BOX 959
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:CT
Mailing Address - Zip Code:06071
Mailing Address - Country:US
Mailing Address - Phone:860-749-8887
Mailing Address - Fax:860-749-7421
Practice Address - Street 1:24 BATTLE STREET
Practice Address - Street 2:SUITE 1A
Practice Address - City:SOMERS
Practice Address - State:CT
Practice Address - Zip Code:06071
Practice Address - Country:US
Practice Address - Phone:860-749-8887
Practice Address - Fax:860-749-7421
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-24
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039732207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03476Medicare UPIN
CTC03476Medicare PIN
CT080001797Medicare PIN