Provider Demographics
NPI:1861514457
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:SENIOR MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TESTANI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-336-7353
Mailing Address - Street 1:3 ENTERPRISE DR
Mailing Address - Street 2:SUITE 404
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4694
Mailing Address - Country:US
Mailing Address - Phone:203-944-1940
Mailing Address - Fax:203-402-4196
Practice Address - Street 1:501 KINGS HWY E
Practice Address - Street 2:SUITE 105
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-4867
Practice Address - Country:US
Practice Address - Phone:203-610-8745
Practice Address - Fax:203-610-8746
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:NORTHEAST MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-04
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD300182588Medicare PIN
CT470000038Medicare PIN