Provider Demographics
NPI:1003849423
Name:FAIRFIELD COUNTY INTERNAL MEDICINE AND GASTROENTEROLOGY ASSOCIATES PC
Entity type:Organization
Organization Name:FAIRFIELD COUNTY INTERNAL MEDICINE AND GASTROENTEROLOGY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-374-4966
Mailing Address - Street 1:4641 MAIN ST STE 1
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1827
Mailing Address - Country:US
Mailing Address - Phone:203-374-4966
Mailing Address - Fax:203-365-6637
Practice Address - Street 1:4641 MAIN ST STE 1
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1827
Practice Address - Country:US
Practice Address - Phone:203-374-4966
Practice Address - Fax:203-371-7024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT015081174400000X
CT043139174400000X
CT019537174400000X
CT014919174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001149194Medicaid
CT001431395Medicaid
CT001195379Medicaid
CT001150812Medicaid
CTE12126Medicare UPIN
CT001195379Medicaid
CTC02557Medicare PIN
CTI36545Medicare UPIN
CTD80709Medicare UPIN