Basic Information
| Provider Information | |||||||||
| NPI: | 1396134664 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHEAST MEDICAL GROUP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 226 MILL HILL AVE STE 3 | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102826 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
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| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036884242 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2015 | ||||||||
| LastUpdateDate: | 01/09/2015 | ||||||||
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| AuthorizedOfficialLastName: | WALDRON | ||||||||
| AuthorizedOfficialFirstName: | CECILIA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 2036881734 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 50684 | CT | Y | Hospitals | General Acute Care Hospital |
No ID Information.