Basic Information
| Provider Information | |||||||||
| NPI: | 1376931311 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ST. VINCENT'S MULTISPECIALTY GROUP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | ST.VINCENT'S PODIATRY CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2660 MAIN ST | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066065369 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035765346 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1825 BARNUM AVE | ||||||||
| Address2: | |||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066145333 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033771777 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/29/2014 | ||||||||
| LastUpdateDate: | 01/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | GLECKLER | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2035765412 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST.VINCENT'S MULTISPECIALTY GROUP, INC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.