Provider Demographics
NPI:1861560922
Name:EASTERN CONNECTICUT EAR, NOSE & THROAT PC
Entity type:Organization
Organization Name:EASTERN CONNECTICUT EAR, NOSE & THROAT PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:TINO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-456-0287
Mailing Address - Street 1:36 WATSON ST
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2122
Mailing Address - Country:US
Mailing Address - Phone:860-456-0287
Mailing Address - Fax:860-456-3532
Practice Address - Street 1:36 WATSON ST
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2122
Practice Address - Country:US
Practice Address - Phone:860-456-0287
Practice Address - Fax:860-456-3532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2018-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207YS0123X, 207YX0602X, 207Y00000X
CT000208332S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No207YS0123XAllopathic & Osteopathic PhysiciansOtolaryngologyFacial Plastic SurgeryGroup - Single Specialty
No207YX0602XAllopathic & Osteopathic PhysiciansOtolaryngologyOtolaryngic AllergyGroup - Single Specialty
No332S00000XSuppliersHearing Aid EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004170742Medicaid
CT004054151Medicaid
CTC01503Medicare ID - Type Unspecified
CT004054151Medicaid