Provider Demographics
NPI:1952596579
Name:COLCHESTER FAMILY MEDICINE LLC
Entity Type:Organization
Organization Name:COLCHESTER FAMILY MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:OLAWALE
Authorized Official - Middle Name:
Authorized Official - Last Name:AYENI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-537-3204
Mailing Address - Street 1:123 BROADWAY ST
Mailing Address - Street 2:P.O. BOX 288
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-1022
Mailing Address - Country:US
Mailing Address - Phone:860-537-3204
Mailing Address - Fax:860-537-3208
Practice Address - Street 1:123 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1022
Practice Address - Country:US
Practice Address - Phone:860-537-3204
Practice Address - Fax:860-537-3208
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-06
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
041093261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
H11409Medicare UPIN