Basic Information
| Provider Information | |||||||||
| NPI: | 1043278351 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 415126 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843975 | ||||||||
| FaxNumber: | 2033843829 | ||||||||
| Practice Location | |||||||||
| Address1: | 226 MILL HILL AVENUE | ||||||||
| Address2: | 3RD FLR | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843975 | ||||||||
| FaxNumber: | 2033843829 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 12/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | BIALCZAK | ||||||||
| AuthorizedOfficialFirstName: | BEATA | ||||||||
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| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2033843975 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207P00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 208600000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 213ES0103X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 207PE0004X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RE0101X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 004112257 | 05 | CT | MEDICAID | 008008038 | 05 | CT | MEDICAID | 004118388 | 05 | CT | MEDICAID | 004223517 | 05 | CT | MEDICAID | 004118396 | 05 | CT | MEDICAID | 008001858 | 05 | CT | MEDICAID | 004212958 | 05 | CT | MEDICAID | 004229317 | 05 | CT | MEDICAID | 008002043 | 05 | CT | MEDICAID | 004216984 | 05 | CT | MEDICAID | 004269173 | 05 | CT | MEDICAID | 004271631 | 05 | CT | MEDICAID |