Provider Demographics
NPI:1730332313
Name:NORWICH INFECTIOUS DISEASE ASSOCIATES LLC
Entity type:Organization
Organization Name:NORWICH INFECTIOUS DISEASE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:J
Authorized Official - Last Name:RAJKUMAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-886-8545
Mailing Address - Street 1:112 LAFAYETTE ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2737
Mailing Address - Country:US
Mailing Address - Phone:860-886-8545
Mailing Address - Fax:855-629-7856
Practice Address - Street 1:112 LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2737
Practice Address - Country:US
Practice Address - Phone:860-886-8545
Practice Address - Fax:855-629-7856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-28
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTI17254174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001386607Medicaid
CT010038660CT02OtherANTHEM
CT9621008OtherCIGNA
CT1730332313OtherAETNA
CT4400000159Medicare NSC