Provider Demographics
NPI:1740571397
Name:EASTERN CONNECTITCUT MEDICAL PROFESSIONALS
Entity type:Organization
Organization Name:EASTERN CONNECTITCUT MEDICAL PROFESSIONALS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOPEDIC PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:KAITLIN
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:VIOLA
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:845-392-7917
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:SUITE 1209
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:SUITE 1209
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:606-598-5104
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-04-29
Last Update Date:2011-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002561282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital