Basic Information
| Provider Information | |||||||||
| NPI: | 1174147052 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRIDGEPORT HOSPITAL | ||||||||
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| OtherOrganizationName: | AMBULATORY SERVICES BRIDGEPORT HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 CHURCH ST S # MCS2 | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036888543 | ||||||||
| FaxNumber: | 2036886005 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2020 | ||||||||
| LastUpdateDate: | 05/28/2021 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MESSINA | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | GERETTE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR, REGULATORY REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 2036888543 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 05/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.