Provider Demographics
NPI:1114120698
Name:NEUROLOGICAL GROUP, PC
Entity Type:Organization
Organization Name:NEUROLOGICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ROSEMARY
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHENSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-443-1891
Mailing Address - Street 1:350 MONTAUK AVE
Mailing Address - Street 2:
Mailing Address - City:NEW LONDON
Mailing Address - State:CT
Mailing Address - Zip Code:06320-4730
Mailing Address - Country:US
Mailing Address - Phone:860-443-1891
Mailing Address - Fax:860-443-2980
Practice Address - Street 1:350 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4730
Practice Address - Country:US
Practice Address - Phone:860-443-1891
Practice Address - Fax:860-443-2980
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT003504OtherSTATE LICENSE
CTQ73149Medicare UPIN