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General NPI Number Information
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NPI Number | 1548642283
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Entity Type | Organization
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Legal Business Name | BRIDGEPORT FAMILY MEDICINE LLC
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Dates
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Enumeration Date | 06/18/2015
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Last Update Date | 06/18/2015
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Provider Practice Location Address
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Address Line | 754 CLINTON AVE
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City | BRIDGEPORT
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State | CT
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Zip | 06604
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Country | US
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Telephone | 203-243-6018
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Fax |
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Provider Business Mailing Address
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Address Line | 112 SUNNYRIDGE AVE
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City | FAIRFIELD
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State | CT
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Zip | 06824-4620
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Country | US
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Telephone | 203-243-6018
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | AWAIS MALIK
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Credential | M.D.,CEO
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Telephone | 203-243-6018
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QU0200X
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Taxonomy Name | Urgent Care Clinic/Center
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License Number | 049851
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 049851
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License Number State | CT
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