Basic Information
| Provider Information | |||||||||
| NPI: | 1912305483 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ST. VINCENTS URGENT CARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 MAIN ST STE 1 | ||||||||
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| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066065363 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1055 POST RD | ||||||||
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| City: | FAIRFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068246019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032593440 | ||||||||
| FaxNumber: | 2032543889 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2014 | ||||||||
| LastUpdateDate: | 03/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | WILLEY | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2035765076 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ST.VINCENTS MULTISPECIALTY GROUP | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.