Healthcare Provider Details

I. General information

NPI: 1174809966
Provider Name (Legal Business Name): PHYSICIAN SERVICES OF NORTHEAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 10/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

PO BOX 8469
BELFAST ME
04915-8469
US

V. Phone/Fax

Practice location:
  • Phone: 860-928-6541
  • Fax: 860-963-6450
Mailing address:
  • Phone: 860-928-6541
  • Fax: 860-963-6450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CHRISTINE L VALLEE
Title or Position: VP PHYSICIAN SERVICES
Credential:
Phone: 860-928-6541