Provider Demographics
NPI:1871807446
Name:BRIDGEPORT HOSPITAL
Entity type:Organization
Organization Name:BRIDGEPORT HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROGRAM DIRECTOR - INTERNAL MEDICIN
Authorized Official - Prefix:DR
Authorized Official - First Name:CONSTANTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:MANTHOUS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-384-3792
Mailing Address - Street 1:100 STONE RIDGE WAY APT 1D
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06824-5392
Mailing Address - Country:US
Mailing Address - Phone:917-225-4744
Mailing Address - Fax:
Practice Address - Street 1:267 GRANT ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06610-2805
Practice Address - Country:US
Practice Address - Phone:203-384-3792
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-05
Last Update Date:2010-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital