Basic Information
| Provider Information | |||||||||
| NPI: | 1679107940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PROGRESSIVE CARE MEDICAL GROUP OF CT, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 EILEEN WAY UNIT 1 | ||||||||
| Address2: | |||||||||
| City: | SYOSSET | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117915313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5168555255 | ||||||||
| FaxNumber: | 5169212451 | ||||||||
| Practice Location | |||||||||
| Address1: | 917 MILL HILL TER | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068903200 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032043012 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2020 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| AuthorizedOfficialLastName: | PATEL | ||||||||
| AuthorizedOfficialFirstName: | DEEPAK | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 5168555255 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 261QP2300X | N | Ambulatory Health Care Facilities | Clinic/Center | Primary Care | 363L00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.