Provider Demographics
NPI: | 1750306015 |
---|---|
Name: | ALLIANCE MEDICAL GROUP OF GREATER WATERBURY PC |
Entity Type: | Organization |
Organization Name: | ALLIANCE MEDICAL GROUP OF GREATER WATERBURY PC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MR |
Authorized Official - First Name: | MARK |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ARESCO |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 203-573-9512 |
Mailing Address - Street 1: | 1625 STRAITS TPKE |
Mailing Address - Street 2: | SUITE #301 |
Mailing Address - City: | MIDDLEBURY |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06762-1836 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 203-573-9512 |
Mailing Address - Fax: | 203-568-2904 |
Practice Address - Street 1: | 1625 STRAITS TPKE |
Practice Address - Street 2: | |
Practice Address - City: | MIDDLEBURY |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06762-1836 |
Practice Address - Country: | US |
Practice Address - Phone: | 203-573-9512 |
Practice Address - Fax: | 203-568-2904 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2006-07-13 |
Last Update Date: | 2009-09-03 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
No | 207RE0101X | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism | Group - Multi-Specialty |
No | 207RI0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease | Group - Multi-Specialty |
No | 207RP1001X | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | Group - Multi-Specialty |
No | 207RR0500X | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | Group - Multi-Specialty |
No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 208M00000X | Allopathic & Osteopathic Physicians | Hospitalist | Group - Multi-Specialty | |
No | 363AM0700X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | Group - Multi-Specialty |
No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
No | 363LG0600X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | Group - Multi-Specialty |
No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 004213005 | Medicaid | |
CT | 004263977 | Medicaid | |
CT | 004203056 | Medicaid | |
CT | 004213013 | Medicaid | |
CT | 004167872 | Medicaid | |
CT | C02054 | Medicare ID - Type Unspecified |