Basic Information
| Provider Information | |||||||||
| NPI: | 1710370390 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MIDDLESEX HOSPITAL | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | MIDDLESEX HOSPITAL AMBULANCE SERVICE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 195 ROUTE 80 | ||||||||
| Address2: | |||||||||
| City: | KILLINGWORTH | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064191400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606633634 | ||||||||
| FaxNumber: | 8606633795 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603586394 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/06/2015 | ||||||||
| LastUpdateDate: | 03/06/2015 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CAPECE | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8603586110 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 3416L0300X | L083P1 | CT | Y | Transportation Services | Ambulance | Land Transport |
ID Information
| ID | Type | State | Issuer | Description | L083P1 | 01 | CT | LICENSE | OTHER |