MEDICARE: MIDSTATE MEDICAL GROUP, PC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	207RS0010X	Sports Medicine (Internal Medicine) Physician
2	207Q00000X	Family Medicine Physician
3	208600000X	Surgery Physician
4	208G00000X	Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
5	2084N0400X	Neurology Physician
6	363L00000X	Nurse Practitioner
7	363A00000X	Physician Assistant
8	207RH0003X	Hematology & Oncology Physician
9	207X00000X	Orthopaedic Surgery Physician
10	207Y00000X	Otolaryngology Physician
11	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1427089598
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIDSTATE MEDICAL GROUP, PC

Provider Business Mailing Address
First Line	:	98 MAIN ST STE 300
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2500
Country	:	US
Telephone Number	:	203-694-5580
Fax Number	:	860-620-0446

Provider Business Practice Location Address
First Line	:	98 MAIN ST STE 300
Second Line	:
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2500
Country	:	US
Telephone Number	:	203-694-5580
Fax Number	:	860-620-0446

Authorized Official
Title or Position	:	VICE PRESIDENT, FINANCE
Name	:	RALPH BECKER
Credential	:
Telephone Number	:	860-545-7602

Provider Enumeration Date	:	07/06/2006
Last Update Date	:	08/24/2012

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Directions to “MIDSTATE MEDICAL GROUP, PC ” Practice Location

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