Basic Information
| Provider Information | |||||||||
| NPI: | 1427007848 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDSTATE MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 4131 | ||||||||
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| City: | YALESVILLE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064921481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032841340 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Practice Location | |||||||||
| Address1: | 435 LEWIS AVENUE | ||||||||
| Address2: | |||||||||
| City: | MERIDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064512101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2036948200 | ||||||||
| FaxNumber: | 8606966035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | BOISVERT | ||||||||
| AuthorizedOfficialFirstName: | GERALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP CFO | ||||||||
| AuthorizedOfficialTelephone: | 8605450585 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 282N00000X | 0070 | CT | N | Hospitals | General Acute Care Hospital | 363LN0000X | N | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 004025078 | 05 | CT | MEDICAID |