Provider Demographics
NPI:1356403323
Name:NEW MILFORD MEDICAL GROUP, LLC
Entity type:Organization
Organization Name:NEW MILFORD MEDICAL GROUP, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTINEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-350-7685
Mailing Address - Street 1:11 OLD PARK LANE RD
Mailing Address - Street 2:
Mailing Address - City:NEW MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06776-2507
Mailing Address - Country:US
Mailing Address - Phone:860-355-1149
Mailing Address - Fax:860-355-5957
Practice Address - Street 1:11 OLD PARK LANE RD
Practice Address - Street 2:
Practice Address - City:NEW MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06776-2507
Practice Address - Country:US
Practice Address - Phone:860-355-1149
Practice Address - Fax:860-355-5957
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4184686Medicaid
CTC02246Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER