Provider Demographics
NPI:1376580258
Name:LEDGE LIGHT MEDICAL ASSOCATES, LLC
Entity Type:Organization
Organization Name:LEDGE LIGHT MEDICAL ASSOCATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:R
Authorized Official - Last Name:BUGGELN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-442-4442
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:419 MONTAUK AVE
Practice Address - Street 2:
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4621
Practice Address - Country:US
Practice Address - Phone:860-442-4442
Practice Address - Fax:860-442-4446
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT035420207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001354208Medicaid
CTE23781Medicare UPIN
D100000007Medicare PIN
CT010000752Medicare PIN