Healthcare Provider Details

I. General information

NPI: 1760537013
Provider Name (Legal Business Name): WEST SIDE MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2007
Last Update Date: 12/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

606 W MAIN ST
NORWICH CT
06360-6007
US

IV. Provider business mailing address

606 W MAIN ST
NORWICH CT
06360-6007
US

V. Phone/Fax

Practice location:
  • Phone: 860-889-1400
  • Fax: 860-889-3163
Mailing address:
  • Phone: 860-889-1400
  • Fax: 860-889-3163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number207Q00000X
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number005383
License Number StateCT

VIII. Authorized Official

Name: DR. WILLIAM H HERNANDEZ III
Title or Position: OWNER
Credential: M.D.
Phone: 860-889-1400