Healthcare Provider Details

I. General information

NPI: 1093138935
Provider Name (Legal Business Name): MHS PRIMARY CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2014
Last Update Date: 04/07/2022
Certification Date: 04/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

154 MAIN ST
OLD SAYBROOK CT
06475-2373
US

IV. Provider business mailing address

28 CRESCENT ST MIDDLESEX HOSPITAL URGENT CARE
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-661-5976
  • Fax: 860-358-8664
Mailing address:
  • Phone: 860-358-4870
  • Fax: 860-358-6748

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT

VIII. Authorized Official

Name: SUSAN MARTIN
Title or Position: VP FINANCE
Credential:
Phone: 860-358-3005