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475 Clinton Ave Bridgeport CT 06605-1700 | |
| (203) 368-4291 | |
| (203) 368-9167 |
| Full Name | |
|---|---|
| Speciality | Clinic/Center |
| Location | 475 Clinton Ave, Bridgeport, Connecticut |
| Authorized Official Name and Position | Frank Farias (CHIEF FINANCIAL & HR OFFICER) |
| Authorized Official Contact | 2033684291 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
475 Clinton Ave Bridgeport CT 06605-1700 Ph: (203) 368-4291 | 475 Clinton Ave Bridgeport CT 06605-1700 Ph: (203) 368-4291 |
| NPI Number | 1922006923 |
|---|---|
| Provider Enumeration Date | 07/13/2005 |
| Last Update Date | 11/18/2020 |
| Certification Date | 11/18/2020 |
| Medicare PECOS PAC ID | 4981595618 |
|---|---|
| Medicare Enrollment ID | O20040323000475 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1922006923 | NPI | - | NPPES |
| 004069985 | Medicaid | CT |
| Provider Name | Sherry Lucke |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1922592732 PECOS PAC ID: 8820346208 Enrollment ID: I20180801000893 |
| Provider Name | Sharda Belcher |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1689370041 PECOS PAC ID: 8224496385 Enrollment ID: I20230621003001 |
| Provider Name | Elaine Barclay |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639410228 PECOS PAC ID: 4284085762 Enrollment ID: I20240109002721 |
| Provider Name | Jessica Marie Davila |
|---|---|
| Provider Type | Practitioner - Mental Health Counselor |
| Provider Identifiers | NPI Number: 1780339200 PECOS PAC ID: 3870027121 Enrollment ID: I20241111000237 |
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