Provider Demographics
NPI:1649256389
Name:MED EAST ASSOCIATES LLC
Entity type:Organization
Organization Name:MED EAST ASSOCIATES LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:A
Authorized Official - Last Name:HAKMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:NA
Authorized Official - Phone:860-456-1252
Mailing Address - Street 1:1703 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1133
Mailing Address - Country:US
Mailing Address - Phone:860-456-1252
Mailing Address - Fax:860-456-2278
Practice Address - Street 1:1703 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1133
Practice Address - Country:US
Practice Address - Phone:860-456-1252
Practice Address - Fax:860-456-2278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-15
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NA261QU0200X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004088755Medicaid
CT=========OtherTAX ID NUMBER
CT=========OtherTAX ID NUMBER