Provider Demographics
NPI:1811929300
Name:COASTAL DIGESTIVE CARE CENTER LLC
Entity type:Organization
Organization Name:COASTAL DIGESTIVE CARE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:FRESE
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:860-442-0290
Mailing Address - Street 1:234A BANK ST
Mailing Address - Street 2:4TH FLOOR
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-447-0402
Mailing Address - Fax:860-447-8117
Practice Address - Street 1:234A BANK ST
Practice Address - Street 2:4TH FLOOR
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-447-0402
Practice Address - Fax:860-447-8117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-07
Last Update Date:2009-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QA1903X
CT0303261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001168194Medicaid
CT001317975Medicaid
CT004223137Medicaid
CT001284083Medicaid
CT001385617Medicaid
CT001385617Medicaid
CT001284083Medicaid
CTB37983Medicare UPIN
CTP47240Medicare UPIN
CT001168194Medicaid
CT100000199Medicare ID - Type UnspecifiedGEORGE OUELLETTE
CT100000043Medicare ID - Type UnspecifiedJOHN MADSEN
CTF03598Medicare UPIN
CT004223137Medicaid
CT500000760Medicare ID - Type UnspecifiedTERESA D'ERRICO