Healthcare Provider Details

I. General information

NPI: 1104824978
Provider Name (Legal Business Name): MOUNT CARMEL INTERNAL MEDICINE AND GERIATRICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 07/21/2022
Certification Date: 03/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 S MAIN ST SUITE 205
CHESHIRE CT
06410-3181
US

IV. Provider business mailing address

5000 BIRCH ST
NEWPORT BEACH CA
92660-2127
US

V. Phone/Fax

Practice location:
  • Phone: 203-699-9898
  • Fax: 203-250-7878
Mailing address:
  • Phone: 301-990-3995
  • Fax: 702-447-8174

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MARIA N.C. STACK
Title or Position: PRESIDENT
Credential: M.D.
Phone: 203-699-9898