MEDICARE: CITY OF BRIDGEPORT HEALTH DEPT. SCHOOL BASED HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QH0100X	Health Service Clinic/Center

General Provider Information

NPI Number	:	1841319803
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CITY OF BRIDGEPORT HEALTH DEPT. SCHOOL BASED HEALTH CENTER

Provider Business Mailing Address
First Line	:	752 E MAIN ST
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06608-2335
Country	:	US
Telephone Number	:	203-576-8090
Fax Number	:

Provider Business Practice Location Address
First Line	:	680 PARK AVE
Second Line	:
City	:	BRIDGEPORT
State	:	CT
Zip	:	06604-4610
Country	:	US
Telephone Number	:	203-576-8090
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF HEALTH
Name	:	DR. MIRIAN EVANS
Credential	:
Telephone Number	:	203-576-7680

Provider Enumeration Date	:	03/28/2007
Last Update Date	:	08/22/2020

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