Healthcare Provider Details

I. General information

NPI: 1366968182
Provider Name (Legal Business Name): MHS PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2017
Last Update Date: 07/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 SAYBROOK RD
MIDDLETOWN CT
06457-4711
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-2780
  • Fax: 860-347-4691
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: SUSAN MARTIN
Title or Position: VICE PRESIDENT FINANCE
Credential:
Phone: 860-358-6140