Provider Demographics
NPI:1366745267
Name:NORTHEAST MEDICAL GROUP, INC
Entity type:Organization
Organization Name:NORTHEAST MEDICAL GROUP, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:NORDGREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-384-3975
Mailing Address - Street 1:226 MILL HILL AVE
Mailing Address - Street 2:3RD FL
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06610-2826
Mailing Address - Country:US
Mailing Address - Phone:203-336-7353
Mailing Address - Fax:203-384-3829
Practice Address - Street 1:1305 POST RD
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-6016
Practice Address - Country:US
Practice Address - Phone:203-292-2000
Practice Address - Fax:203-255-5212
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-12-15
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty