Provider Demographics
NPI:1871744243
Name:WAIRE LLC
Entity type:Organization
Organization Name:WAIRE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ERUM
Authorized Official - Middle Name:
Authorized Official - Last Name:SHAHAB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-871-5402
Mailing Address - Street 1:105 WEST RD
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06029-4247
Mailing Address - Country:US
Mailing Address - Phone:860-871-5402
Mailing Address - Fax:860-871-5413
Practice Address - Street 1:105 WEST RD
Practice Address - Street 2:
Practice Address - City:ELLINGTON
Practice Address - State:CT
Practice Address - Zip Code:06029-5700
Practice Address - Country:US
Practice Address - Phone:860-871-5402
Practice Address - Fax:860-871-5413
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0431122084P0800X, 2084P0802X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction PsychiatryGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty