Healthcare Provider Details

I. General information

NPI: 1114062114
Provider Name (Legal Business Name): MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP EAST HAMPTON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

42 E HIGH ST
EAST HAMPTON CT
06424-1099
US

IV. Provider business mailing address

90 S MAIN ST
MIDDLETOWN CT
06457-3649
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-6394
  • Fax: 860-344-6748
Mailing address:
  • Phone: 860-358-6394
  • Fax: 860-358-6094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateCT

VIII. Authorized Official

Name: MARISA PELLERIN
Title or Position: CREDENTIALING/ENROLLMENT
Credential:
Phone: 860-358-4821