=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396935615
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHWEST CONNECTICUT PHYSICIANS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/01/2007
-----------------------------------------------------
Last Update Date | 06/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 895 EAST MAIN ST
-----------------------------------------------------
City | TORRINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06790-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-489-1291
-----------------------------------------------------
Fax | 860-489-1804
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 895 EAST MAIN ST
-----------------------------------------------------
City | TORRINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06790-3918
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-489-1291
-----------------------------------------------------
Fax | 860-489-1804
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PARTNER
-----------------------------------------------------
Name | DR. DENNIS JAY GOTTFRIED
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-489-1291
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 004854
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 021448
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------