=====================================================
General NPI Number Information
=====================================================
NPI Number | 1346543642
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | POURKAVOOS MEDICAL CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2010
-----------------------------------------------------
Last Update Date | 12/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 35 NOD RD SUITE 205
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-3826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-676-0090
-----------------------------------------------------
Fax | 860-676-0040
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 35 NOD RD SUITE 205
-----------------------------------------------------
City | AVON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06001-3826
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-676-0090
-----------------------------------------------------
Fax | 860-676-0040
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. KHOSRO POURKAVOOS
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-676-0090
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 039709
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------