Provider Demographics
NPI:1295754273
Name:SOUTHEASTERN PULMONARY ASSOC. PC
Entity type:Organization
Organization Name:SOUTHEASTERN PULMONARY ASSOC. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:URBANETTI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-444-2223
Mailing Address - Street 1:155 MONTAUK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320
Mailing Address - Country:US
Mailing Address - Phone:860-444-2223
Mailing Address - Fax:860-440-3153
Practice Address - Street 1:155 MONTAUK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320
Practice Address - Country:US
Practice Address - Phone:860-444-2223
Practice Address - Fax:860-440-3153
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT022057207RP1001X
CT022011207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1220573Medicaid
CT022057OtherLIC DR ROBERT KELTNER
CT1220110Medicaid
2990000061Medicare ID - Type UnspecifiedDR ROBERT KELTNER
CT1220573Medicaid
B83788Medicare UPIN
CT022057OtherLIC DR ROBERT KELTNER
B83788Medicare UPIN
290000060Medicare ID - Type UnspecifiedDR JOHN S URBANETTI