Provider Demographics
NPI:1124535729
Name:LONGEVITY GROUP LLC
Entity Type:Organization
Organization Name:LONGEVITY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BODROGNE SZABO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-484-3251
Mailing Address - Street 1:57 MIRANDA WAY
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:MA
Mailing Address - Zip Code:02324-1481
Mailing Address - Country:US
Mailing Address - Phone:508-697-6385
Mailing Address - Fax:978-630-6052
Practice Address - Street 1:76 N BEDFORD ST UNIT A-4
Practice Address - Street 2:
Practice Address - City:EAST BRIDGEWATER
Practice Address - State:MA
Practice Address - Zip Code:02333-1182
Practice Address - Country:US
Practice Address - Phone:598-484-3251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-04
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA103TP2701X
167G00000X
MA2339622084A0401X, 2084P0015X, 2084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No103TP2701XBehavioral Health & Social Service ProvidersPsychologistGroup PsychotherapyGroup - Single Specialty
No167G00000XNursing Service ProvidersLicensed Psychiatric TechnicianGroup - Single Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction MedicineGroup - Single Specialty
No2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic MedicineGroup - Single Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Single Specialty