=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447231865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NES MEDICAL SERVICES OF NORTHERN CONNECTICUT, P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/11/2005
-----------------------------------------------------
Last Update Date | 10/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 320 POMFRET ST
-----------------------------------------------------
City | PUTNAM
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06260-1836
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-928-6541
-----------------------------------------------------
Fax | 860-963-6368
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7300 STATE HIGHWAY 121 STE 300-374
-----------------------------------------------------
City | MCKINNEY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75070-1987
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 469-557-6183
-----------------------------------------------------
Fax | 469-640-6671
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROVIDER ENROLLMENT
-----------------------------------------------------
Name | JENNIFER BLAKEMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 469-557-6183
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208M00000X
-----------------------------------------------------
Taxonomy Name | Hospitalist Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------