Basic Information
| Provider Information | |||||||||
| NPI: | 1205806791 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIN | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | T | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 E RIVER DR | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824133 | ||||||||
| FaxNumber: | 8602890746 | ||||||||
| Practice Location | |||||||||
| Address1: | 99 E RIVER DR | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061083288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824133 | ||||||||
| FaxNumber: | 8602890746 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2006 | ||||||||
| LastUpdateDate: | 05/09/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 034313 | CT | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 001343136 | 05 | CT | MEDICAID |