Provider Demographics
NPI:1578964961
Name:AMB MEDICAL SERVICES
Entity Type:Organization
Organization Name:AMB MEDICAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANALIA
Authorized Official - Middle Name:BAPTISTA
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:203-895-4360
Mailing Address - Street 1:135 CEDARHURST LN
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-2723
Mailing Address - Country:US
Mailing Address - Phone:203-895-4360
Mailing Address - Fax:
Practice Address - Street 1:135 CEDARHURST LN
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06461-2723
Practice Address - Country:US
Practice Address - Phone:203-895-4360
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-04
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005026363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1699023168Medicaid
CT1699023168Medicaid