Basic Information
| Provider Information | |||||||||
| NPI: | 1568597128 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP PORTLAND | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 S MAIN ST | ||||||||
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| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603446394 | ||||||||
| FaxNumber: | 8603446748 | ||||||||
| Practice Location | |||||||||
| Address1: | 595 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064801156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603446394 | ||||||||
| FaxNumber: | 8603446748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/23/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | CAPECE | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | SR VP FINANCR & OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 8603446394 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207QG0300X | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 363AM0700X | CT | X | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.