Provider Demographics
NPI:1821390626
Name:NORTHEAST MEDICAL GROUP INC
Entity Type:Organization
Organization Name:NORTHEAST MEDICAL GROUP INC
Other - Org Name:NORTHEAST MEDICAL GROUP GREENWICH RADIATION ONCOLOGY
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-384-3717
Mailing Address - Street 1:PO BOX 417143
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-0001
Mailing Address - Country:US
Mailing Address - Phone:615-746-4711
Mailing Address - Fax:
Practice Address - Street 1:77 LAFAYETTE PL
Practice Address - Street 2:SUITE 290
Practice Address - City:GREENWICH
Practice Address - State:CT
Practice Address - Zip Code:06830-5426
Practice Address - Country:US
Practice Address - Phone:203-863-3701
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0470922085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00995Medicare PIN