Provider Demographics
NPI:1396935615
Name:NORTHWEST CONNECTICUT PHYSICIANS LLC
Entity type:Organization
Organization Name:NORTHWEST CONNECTICUT PHYSICIANS LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:GOTTFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-489-1291
Mailing Address - Street 1:895 EAST MAIN ST
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-3918
Mailing Address - Country:US
Mailing Address - Phone:860-489-1291
Mailing Address - Fax:860-489-1804
Practice Address - Street 1:895 EAST MAIN ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-3918
Practice Address - Country:US
Practice Address - Phone:860-489-1291
Practice Address - Fax:860-489-1804
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-01
Last Update Date:2014-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004854363LA2200X
CT021448207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004394904Medicaid
CTC01177Medicare PIN