Provider Demographics
NPI:1366582363
Name:EASTERN CT HEMATOLOGY & ONCOLOGY
Entity type:Organization
Organization Name:EASTERN CT HEMATOLOGY & ONCOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIAILIST
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:916-233-8607
Mailing Address - Street 1:330 WASHINGTON ST
Mailing Address - Street 2:SUITE 220
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2700
Mailing Address - Country:US
Mailing Address - Phone:860-886-8362
Mailing Address - Fax:860-886-9262
Practice Address - Street 1:330 WASHINGTON ST STE 220
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2700
Practice Address - Country:US
Practice Address - Phone:860-886-8362
Practice Address - Fax:860-886-9262
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004396174Medicaid
CT004247145Medicaid