Healthcare Provider Details

I. General information

NPI: 1750783619
Provider Name (Legal Business Name): THOMPSON MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2014
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 RIVERSIDE DR
NORTH GROSVENORDALE CT
06255-2165
US

IV. Provider business mailing address

415 RIVERSIDE DR
NORTH GROSVENORDALE CT
06255-2165
US

V. Phone/Fax

Practice location:
  • Phone: 860-923-1190
  • Fax: 860-923-0134
Mailing address:
  • Phone: 860-923-1190
  • Fax: 860-923-0134

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LISA A CODERRE
Title or Position: OFFICE MANAGER
Credential:
Phone: 860-923-1181