Healthcare Provider Details

I. General information

NPI: 1497462139
Provider Name (Legal Business Name): AMERICAS VETERANS AND PCP CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2022
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2044 BRIDGEPORT AVE STE K
MILFORD CT
06460-4633
US

IV. Provider business mailing address

600 MAIN ST
WORCESTER MA
01608-2061
US

V. Phone/Fax

Practice location:
  • Phone: 216-688-9320
  • Fax: 203-951-3668
Mailing address:
  • Phone: 216-688-9320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QX0200X
TaxonomyOncology Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number StateNULL
# 7
Primary TaxonomyN
Taxonomy Code2084E0001X
TaxonomyEpilepsy Physician
License Number
License Number StateNULL
# 8
Primary TaxonomyN
Taxonomy Code207RA0001X
TaxonomyAdvanced Heart Failure and Transplant Cardiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: JAY J. IDREES
Title or Position: CLINICAL PROGRAM DIRECTOR
Credential: MD
Phone: 216-688-9320