Healthcare Provider Details

I. General information

NPI: 1215436894
Provider Name (Legal Business Name): MHS PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2018
Last Update Date: 02/07/2022
Certification Date: 02/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9 WILDWOOD MEDICAL CTR UNIT 2
ESSEX CT
06426-1155
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-3170
  • Fax: 860-358-8666
Mailing address:
  • Phone: 860-358-4820
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUSAN MARTIN
Title or Position: NETWORK EXECUTIVE
Credential:
Phone: 860-358-4802