Basic Information
| Provider Information | |||||||||
| NPI: | 1316022718 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDSTATE MEDICAL CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IP PSYCH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 435 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606966287 | ||||||||
| FaxNumber: | 8606966035 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 LEWIS AVE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606966287 | ||||||||
| FaxNumber: | 8606966035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BECKER | ||||||||
| AuthorizedOfficialFirstName: | RALPH | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8606966220 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0070 | CT | Y | Hospital Units | Psychiatric Unit |
No ID Information.