=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588634695
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NEWINGTON INTERNAL MEDICINE PRIMARY CARE,LLP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2006
-----------------------------------------------------
Last Update Date | 11/04/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 365 WILLARD AVE SUITE 2-D
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-665-1571
-----------------------------------------------------
Fax | 860-665-1571
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 365 WILLARD AVE SUITE 2-D
-----------------------------------------------------
City | NEWINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06111-2373
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-665-1571
-----------------------------------------------------
Fax | 860-665-1571
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGING PARTNER
-----------------------------------------------------
Name | JEFFREY MARK KAGAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 860-665-1571
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------