Healthcare Provider Details

I. General information

NPI: 1760940035
Provider Name (Legal Business Name): MIDDLESEX HOSPITAL DBA MIDDLESEX HOSPITAL PHYSICIAN SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

540 SAYBROOK RD STE 210
MIDDLETOWN CT
06457-4759
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-358-6875
  • Fax: 860-358-8693
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number StateNULL

VIII. Authorized Official

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