Provider Demographics
| NPI: | 1770557712 |
|---|---|
| Name: | EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION INC |
| Entity type: | Organization |
| Organization Name: | EASTERN CONNECTICUT MEDICAL PROFESSIONALS FOUNDATION INC |
| Other - Org Name: | <UNAVAIL> |
| Other - Org Type: | |
| Authorized Official - Title/Position: | PRESIDENT & CEO |
| Authorized Official - Prefix: | |
| Authorized Official - First Name: | PETER |
| Authorized Official - Middle Name: | J |
| Authorized Official - Last Name: | KARL |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 860-646-1222 |
| Mailing Address - Street 1: | 71 HAYNES ST |
| Mailing Address - Street 2: | MILLER BLDG, FLOOR G |
| Mailing Address - City: | MANCHESTER |
| Mailing Address - State: | CT |
| Mailing Address - Zip Code: | 06040-4131 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 860-533-2981 |
| Mailing Address - Fax: | 860-533-2975 |
| Practice Address - Street 1: | 71 HAYNES ST |
| Practice Address - Street 2: | MILLER BLDG, FLOOR G |
| Practice Address - City: | MANCHESTER |
| Practice Address - State: | CT |
| Practice Address - Zip Code: | 06040-4131 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 860-533-2981 |
| Practice Address - Fax: | 860-533-2975 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-02-15 |
| Last Update Date: | 2013-10-03 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 207R00000X, 207RE0101X, 207RG0100X, 208600000X, 208M00000X, 363AM0700X, 363L00000X, 207X00000X, 2086S0129X, 208G00000X, 207VX0201X, 207Q00000X | ||
| CT | 101YP2500X, 106H00000X, 1041C0700X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
| No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
| No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Group - Multi-Specialty | |
| No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
| No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
| No | 101YP2500X | Behavioral Health & Social Service Providers | Counselor | Professional | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 207VX0201X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecologic Oncology | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CT | 004212750 | Medicaid | |
| CT | 004271285 | Medicaid | |
| CT | 004268571 | Medicaid | |
| CT | 004271300 | Medicaid | |
| CT | 01003917CT05 | Other | ANTHEM ID - ALI HEMACHA, MD |
| CT | 004268620 | Medicaid | |
| CT | 004181351 | Medicaid | |
| CT | 004271285 | Medicaid |
