Healthcare Provider Details

I. General information

NPI: 1275801771
Provider Name (Legal Business Name): PHYSICIAN SERVICES OF NORTHEAST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2011
Last Update Date: 12/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 POMFRET ST SUITE CSB2
PUTNAM CT
06260-1836
US

IV. Provider business mailing address

320 POMFRET ST
PUTNAM CT
06260-1836
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 TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JULIE DROUIN
Title or Position: CFO
Credential:
Phone: 860-928-6541