Basic Information
| Provider Information | |||||||||
| NPI: | 1114062114 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP EAST HAMPTON | ||||||||
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| OtherOrganizationName: | FAMILY PRACTICE GROUP EAST HAMPTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603586394 | ||||||||
| FaxNumber: | 8603586094 | ||||||||
| Practice Location | |||||||||
| Address1: | 42 E HIGH ST | ||||||||
| Address2: | |||||||||
| City: | EAST HAMPTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064241099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603446394 | ||||||||
| FaxNumber: | 8603446748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2007 | ||||||||
| LastUpdateDate: | 03/06/2019 | ||||||||
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| AuthorizedOfficialLastName: | PELLERIN | ||||||||
| AuthorizedOfficialFirstName: | MARISA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING/ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 8603584821 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDDLESEX HOSPITAL | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207QG0300X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207V00000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363AM0700X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 207Q00000X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.