Provider Demographics
NPI:1639195415
Name:FAIRFIELD COUNTY MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:FAIRFIELD COUNTY MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:
Authorized Official - Last Name:SPANO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-459-5100
Mailing Address - Street 1:15 CORPORATE DR
Mailing Address - Street 2:SUITE 2-1
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-1351
Mailing Address - Country:US
Mailing Address - Phone:203-459-5100
Mailing Address - Fax:203-452-2424
Practice Address - Street 1:15 CORPORATE DR
Practice Address - Street 2:SUITE 2-1
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1351
Practice Address - Country:US
Practice Address - Phone:203-459-5100
Practice Address - Fax:203-452-2424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC12675OtherRAILROAD MEDICARE PTAN
CT50FFLDCMGCT01OtherANTHEM BLUE CROSS BLUE SH
CT=========OtherAETNA
CT=========OtherCIGNA HEALTHCARE OF CT
CTC12675OtherRAILROAD MEDICARE PTAN
CT50FFLDCMGCT01OtherANTHEM BLUE CROSS BLUE SH
CT=========OtherUNITED HEALTH CARE
CT=========OtherUNITED HEALTH CARE
CTC01579Medicare ID - Type Unspecified
CTC12675OtherRAILROAD MEDICARE PTAN
CTE44796Medicare UPIN
CTS53756Medicare UPIN
CTH54952Medicare UPIN
COH57774Medicare UPIN
CTI01335Medicare UPIN