Basic Information
| Provider Information | |||||||||
| NPI: | 1134436694 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGEPORT HOSPTTAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 228 HULLS HWY | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068901185 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032928004 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | 2033844692 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/05/2010 | ||||||||
| LastUpdateDate: | 09/05/2010 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | HARRIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF PEDIATRICS | ||||||||
| AuthorizedOfficialTelephone: | 2033843000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 3703 | CT | Y | Hospitals | General Acute Care Hospital |
No ID Information.