Provider Demographics
NPI:1265426332
Name:COUNTY OBSTETRICS AND GYNECOLOGY GROUP
Entity type:Organization
Organization Name:COUNTY OBSTETRICS AND GYNECOLOGY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TINA
Authorized Official - Middle Name:
Authorized Official - Last Name:D'AMICO
Authorized Official - Suffix:
Authorized Official - Credentials:MHA
Authorized Official - Phone:203-315-7071
Mailing Address - Street 1:687 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3612
Mailing Address - Country:US
Mailing Address - Phone:203-488-8306
Mailing Address - Fax:203-481-0267
Practice Address - Street 1:687 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3612
Practice Address - Country:US
Practice Address - Phone:203-488-8306
Practice Address - Fax:203-481-0267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-06
Last Update Date:2009-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004141264Medicaid
CT004141264Medicaid