Provider Demographics
NPI:1407864762
Name:PRIMED GASTROENTEROLOGY, LLC
Entity Type:Organization
Organization Name:PRIMED GASTROENTEROLOGY, LLC
Other - Org Name:FAIRFIELD COUNTY ENDOSCOPY CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-268-1193
Mailing Address - Street 1:888 WHITE PLAINS RD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4552
Mailing Address - Country:US
Mailing Address - Phone:203-268-1193
Mailing Address - Fax:
Practice Address - Street 1:888 WHITE PLAINS RD
Practice Address - Street 2:SUITE 210
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4552
Practice Address - Country:US
Practice Address - Phone:203-268-1193
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRIMED, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-03
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0276261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT490000231Medicare ID - Type UnspecifiedPROVIDER NUMBER