Provider Demographics
NPI:1205489077
Name:ST VINCENTS MULTISPECIALTY GROUP INC
Entity type:Organization
Organization Name:ST VINCENTS MULTISPECIALTY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LLATOYA
Authorized Official - Middle Name:
Authorized Official - Last Name:GAYLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:475-210-5346
Mailing Address - Street 1:2720 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5363
Mailing Address - Country:US
Mailing Address - Phone:475-210-5346
Mailing Address - Fax:
Practice Address - Street 1:2409 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5324
Practice Address - Country:US
Practice Address - Phone:203-334-6955
Practice Address - Fax:203-334-2851
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST VINCENTS MULTISPECIALTY GROUP INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty