Basic Information
| Provider Information | |||||||||
| NPI: | 1396055356 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTH BRIDGE IMAGING GROUP, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTH BRIDGE VEIN CARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 15 CENTER ST | ||||||||
| Address2: | |||||||||
| City: | FAIRHAVEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 027192928 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089466898 | ||||||||
| FaxNumber: | 5089461494 | ||||||||
| Practice Location | |||||||||
| Address1: | 22 MILL ST | ||||||||
| Address2: | SUITE 304 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 024764784 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5089466898 | ||||||||
| FaxNumber: | 5089461494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2010 | ||||||||
| LastUpdateDate: | 10/22/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROSE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | I. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9782873794 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTH BRIDGE IMAGING GROUP, LLC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
No ID Information.