Provider Demographics
NPI:1174603682
Name:MEDICAL ASSOCIATES OF NORTH HAVEN LLC
Entity type:Organization
Organization Name:MEDICAL ASSOCIATES OF NORTH HAVEN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:IDA
Authorized Official - Middle Name:
Authorized Official - Last Name:SANSONE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-234-1891
Mailing Address - Street 1:100 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2365
Mailing Address - Country:US
Mailing Address - Phone:203-234-1891
Mailing Address - Fax:203-234-7037
Practice Address - Street 1:100 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2365
Practice Address - Country:US
Practice Address - Phone:203-234-1891
Practice Address - Fax:203-234-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004220464Medicaid
CTC02434Medicare PIN