1043278351 NPI number — NORTHEAST MEDICAL GROUP, INC.

Table of content: (NPI 1043278351)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043278351 NPI number — NORTHEAST MEDICAL GROUP, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MEDICAL GROUP, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043278351
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/22/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 415126
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BOSTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02241-0001
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-384-3975
Provider Business Mailing Address Fax Number:
203-384-3829

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
226 MILL HILL AVENUE
Provider Second Line Business Practice Location Address:
3RD FLR
Provider Business Practice Location Address City Name:
BRIDGEPORT
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06610
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-384-3975
Provider Business Practice Location Address Fax Number:
203-384-3829
Provider Enumeration Date:
05/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BIALCZAK
Authorized Official First Name:
BEATA
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGER
Authorized Official Telephone Number:
203-384-3975

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 106H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 133V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207PE0004X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207RC0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RE0101X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 367500000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 004112257 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008008038 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004118388 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004223517 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004118396 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008001858 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004212958 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004229317 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 008002043 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004216984 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004269173 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".
  • Identifier: 004271631 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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