Healthcare Provider Details

I. General information

NPI: 1649256389
Provider Name (Legal Business Name): MED EAST ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 06/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1703 MAIN ST
WILLIMANTIC CT
06226-1133
US

IV. Provider business mailing address

1703 MAIN ST
WILLIMANTIC CT
06226-1133
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-1252
  • Fax: 860-456-2278
Mailing address:
  • Phone: 860-456-1252
  • Fax: 860-456-2278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License NumberNA
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. MARIE A HAKMILLER
Title or Position: ADMINISTRATOR
Credential: NA
Phone: 860-456-1252