Healthcare Provider Details

I. General information

NPI: 1730566381
Provider Name (Legal Business Name): FAMILY MEDICINE CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 05/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

574 MIDDLE TPKE E
MANCHESTER CT
06040-3730
US

IV. Provider business mailing address

574 MIDDLE TPKE E
MANCHESTER CT
06040-3730
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-4334
  • Fax: 860-646-7020
Mailing address:
  • Phone: 860-646-4334
  • Fax: 860-646-7020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number3317
License Number StateCT

VIII. Authorized Official

Name: DENISE L. MACLEOD
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-573-2900