Provider Demographics
NPI:1700898764
Name:EAST HARTFORD PEDIATRIC, LLC.
Entity Type:Organization
Organization Name:EAST HARTFORD PEDIATRIC, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAYASHREE
Authorized Official - Middle Name:
Authorized Official - Last Name:VENKATESH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-289-3047
Mailing Address - Street 1:21 PAUL SPRING RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032
Mailing Address - Country:US
Mailing Address - Phone:860-676-1135
Mailing Address - Fax:
Practice Address - Street 1:893 MAIN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:EAST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06108-2292
Practice Address - Country:US
Practice Address - Phone:860-289-3047
Practice Address - Fax:860-528-4735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2014-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034733172V00000X
CT002155363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Single Specialty
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008035516Medicaid
CT001347336Medicaid