Provider Demographics
NPI:1730566381
Name:FAMILY MEDICINE CENTER
Entity type:Organization
Organization Name:FAMILY MEDICINE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACLEOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-573-2900
Mailing Address - Street 1:574 MIDDLE TPKE E
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3730
Mailing Address - Country:US
Mailing Address - Phone:860-646-4334
Mailing Address - Fax:860-646-7020
Practice Address - Street 1:574 MIDDLE TPKE E
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3730
Practice Address - Country:US
Practice Address - Phone:860-646-4334
Practice Address - Fax:860-646-7020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3317363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty