Basic Information
| Provider Information | |||||||||
| NPI: | 1710935002 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COTTAGE GROVE CARDIOLOGY, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 711 COTTAGE GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Practice Location | |||||||||
| Address1: | 711 COTTAGE GROVE ROAD | ||||||||
| Address2: | |||||||||
| City: | BLOOMFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060023060 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602428756 | ||||||||
| FaxNumber: | 8602423052 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 11/05/2014 | ||||||||
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| AuthorizedOfficialLastName: | SIMONS | ||||||||
| AuthorizedOfficialFirstName: | STACY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OFFICE ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 8602428756 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 363L00000X | 002892 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 5854 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 3110 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207RC0000X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | C00718 | 01 | CT | MEDICARE | OTHER | 004090958 | 05 | CT | MEDICAID | CA8569 | 01 | RAILROAD MEDICARE | OTHER |