Healthcare Provider Details

I. General information

NPI: 1952586000
Provider Name (Legal Business Name): PARTNERS IN PRIMARY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2008
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1358 BOSTON POST RD UNIT 1
OLD SAYBROOK CT
06475-1749
US

IV. Provider business mailing address

1358 BOSTON POST RD UNIT 1
OLD SAYBROOK CT
06475-1749
US

V. Phone/Fax

Practice location:
  • Phone: 860-510-0792
  • Fax: 860-510-0793
Mailing address:
  • Phone: 860-510-0792
  • Fax: 860-510-0793

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036811
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number042678
License Number StateCT

VIII. Authorized Official

Name: DR. DAVID JONATHAN FREDERIKS
Title or Position: MEMBER
Credential: MD
Phone: 860-510-0792