Healthcare Provider Details

I. General information

NPI: 1558473769
Provider Name (Legal Business Name): THOMAS KUCHARCHIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2006
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 GOLD STAR HWY SUITE 100
GROTON CT
06340-6702
US

IV. Provider business mailing address

635 MAIN ST ATTN: CREDENTIALING DPT
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-8858
  • Fax: 860-405-2140
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number25896
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9785
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: