MEDICARE: CCT CARE OF CT, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0011X	Interventional Cardiology Physician
2	207RC0000X	Cardiovascular Disease Physician

General Provider Information

NPI Number	:	1316408545
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CCT CARE OF CT, LLC

Provider Business Mailing Address
First Line	:	102 WOODMONT BLVD STE 350
Second Line	:
City	:	NASHVILLE
State	:	TN
Zip	:	37205-2216
Country	:	US
Telephone Number	:	615-386-0064
Fax Number	:

Provider Business Practice Location Address
First Line	:	2389 MAIN ST
Second Line	:
City	:	GLASTONBURY
State	:	CT
Zip	:	06033-4617
Country	:	US
Telephone Number	:	615-386-0064
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	EDWARD LELAND HUTTON EADIE
Credential	:
Telephone Number	:	615-733-2064

Provider Enumeration Date	:	03/29/2019
Last Update Date	:	02/13/2020

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