Basic Information
| Provider Information | |||||||||
| NPI: | 1174734768 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALSAMARAI | ||||||||
| FirstName: | SUSAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 455 LEWIS AVE | ||||||||
| Address2: | MIDSTATE MEDICAL GROUP, PC | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032387747 | ||||||||
| FaxNumber: | 2032387747 | ||||||||
| Practice Location | |||||||||
| Address1: | 455 LEWIS AVE | ||||||||
| Address2: | MIDSTATE MEDICAL GROUP, PC | ||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512121 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032387747 | ||||||||
| FaxNumber: | 2036860282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2007 | ||||||||
| LastUpdateDate: | 06/24/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 248940 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 050729 | CT | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RH0003X | 050729 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | CT | MEDICAID |