Provider Demographics
NPI:1902230030
Name:NORTH END MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:NORTH END MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:WAYNE
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEVIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-579-9000
Mailing Address - Street 1:3690 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-3610
Mailing Address - Country:US
Mailing Address - Phone:203-579-9000
Mailing Address - Fax:203-374-6132
Practice Address - Street 1:3690 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-3610
Practice Address - Country:US
Practice Address - Phone:203-579-9000
Practice Address - Fax:203-374-6132
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-26
Last Update Date:2013-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT050053207Q00000X
CT020625207R00000X
CT047525207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty