Healthcare Provider Details

I. General information

NPI: 1720182876
Provider Name (Legal Business Name): LAURIE S BRIDGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

374 GRAND AVE FAIR HAVEN COMMUNITY HEALTH CENTER
NEW HAVEN CT
06513
US

IV. Provider business mailing address

47 MARVEL ROAD
NEW HAVEN CT
06515
US

V. Phone/Fax

Practice location:
  • Phone: 203-777-7411
  • Fax: 203-777-8506
Mailing address:
  • Phone: 203-387-6705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number031428
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: