Basic Information
| Provider Information | |||||||||
| NPI: | 1366745267 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST MEDICAL GROUP, INC | ||||||||
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| OtherOrganizationName: | CARDIAC SPECIALISTS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 226 MILL HILL AVE | ||||||||
| Address2: | 3RD FL | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033367353 | ||||||||
| FaxNumber: | 2033843829 | ||||||||
| Practice Location | |||||||||
| Address1: | 1305 POST RD | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068246016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032922000 | ||||||||
| FaxNumber: | 2032555212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2010 | ||||||||
| LastUpdateDate: | 07/31/2013 | ||||||||
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| AuthorizedOfficialLastName: | NORDGREN | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2033843975 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHEAST MEDICAL GROUP, INC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | M.D | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
No ID Information.