Healthcare Provider Details

I. General information

NPI: 1699099630
Provider Name (Legal Business Name): OCCUPATIONAL MEDICINE OF THE NORTHEAST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2010
Last Update Date: 08/14/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 EAST ST
PLAINVILLE CT
06062-2935
US

IV. Provider business mailing address

240 EAST ST
PLAINVILLE CT
06062-2935
US

V. Phone/Fax

Practice location:
  • Phone: 860-747-4541
  • Fax: 860-793-1218
Mailing address:
  • Phone: 860-747-4541
  • Fax: 860-793-1218

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number027429
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: DR. STEPHEN A KEI
Title or Position: MEMBER
Credential: M.D.
Phone: 860-747-4541