Provider Demographics
NPI:1932295953
Name:GERIATRIC PROFESSIONAL GROUP, LLC
Entity Type:Organization
Organization Name:GERIATRIC PROFESSIONAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:H
Authorized Official - Last Name:BANOFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-365-6400
Mailing Address - Street 1:4200 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-1049
Mailing Address - Country:US
Mailing Address - Phone:203-365-6473
Mailing Address - Fax:203-396-1039
Practice Address - Street 1:4200 PARK AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-1049
Practice Address - Country:US
Practice Address - Phone:203-365-6473
Practice Address - Fax:203-396-1039
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-05
Last Update Date:2016-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207R00000X
CT207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT9233Medicaid
CTC02995Medicare UPIN