Basic Information
| Provider Information | |||||||||
| NPI: | 1336279058 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MHS PRIMARY CARE, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603584820 | ||||||||
| FaxNumber: | 8603588661 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2007 | ||||||||
| LastUpdateDate: | 05/03/2021 | ||||||||
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| AuthorizedOfficialLastName: | MARTIN | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8603583005 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207R00000X | 023007 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | 000621 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363LF0000X | 002921 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207Q00000X | 023007 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 04201084 | 05 | CT | MEDICAID | 04173259 | 05 | CT | MEDICAID | 008073532 | 05 | CT | MEDICAID | 04181343 | 05 | CT | MEDICAID |