Healthcare Provider Details

I. General information

NPI: 1710104625
Provider Name (Legal Business Name): MHS PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 09/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 MAIN ST
PORTLAND CT
06480-1857
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-342-3392
  • Fax: 860-358-8658
Mailing address:
  • Phone: 860-358-4819
  • Fax: 860-632-0240

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. SUSAN SERKEY
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 860-358-4802