Basic Information
| Provider Information | |||||||||
| NPI: | 1093838195 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH BRIDGE IMAGING GROUP, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | FAIRHAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027192928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089473970 | ||||||||
| FaxNumber: | 5089461494 | ||||||||
| Practice Location | |||||||||
| Address1: | 133 OLD ROAD TO 9 ACRE COR | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | MA | ||||||||
| PostalCode: | 017424159 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9782873700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | I. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9782873794 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085D0003X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Neuroimaging |
ID Information
| ID | Type | State | Issuer | Description | 9716190 | 05 | MA | MEDICAID |