Basic Information
| Provider Information | |||||||||
| NPI: | 1821390626 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHEAST MEDICAL GROUP INC | ||||||||
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| OtherOrganizationName: | NORTHEAST MEDICAL GROUP GREENWICH RADIATION ONCOLOGY | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 417143 | ||||||||
| Address2: | |||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 022410001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6157464711 | ||||||||
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| Practice Location | |||||||||
| Address1: | 77 LAFAYETTE PL | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | GREENWICH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068305426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038633701 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/30/2010 | ||||||||
| LastUpdateDate: | 11/30/2010 | ||||||||
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| AuthorizedOfficialLastName: | MCDONALD | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2033843717 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0001X | 047092 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.