Healthcare Provider Details

I. General information

NPI: 1861560922
Provider Name (Legal Business Name): EASTERN CONNECTICUT EAR, NOSE & THROAT PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 02/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

36 WATSON ST
WILLIMANTIC CT
06226-2122
US

IV. Provider business mailing address

36 WATSON ST
WILLIMANTIC CT
06226-2122
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-0287
  • Fax: 860-456-3532
Mailing address:
  • Phone: 860-456-0287
  • Fax: 860-456-3532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code332S00000X
TaxonomyHearing Aid Equipment
License Number000208
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DEBRA TINO
Title or Position: PRACTICE MANAGER
Credential:
Phone: 860-456-0287