Basic Information
| Provider Information | |||||||||
| NPI: | 1760451041 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLESEX HOSPITAL | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIDDLESEX HOSPITAL DBA MIDDLESEX HOSPITAL PSYCHIATRIC PHYSICIAN SERVIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603586394 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Practice Location | |||||||||
| Address1: | 28 CRESCENT ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573654 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603586394 | ||||||||
| FaxNumber: | 8603586748 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2006 | ||||||||
| LastUpdateDate: | 11/01/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | CAPECE | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8603586394 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MIDDLESEX HOSPITAL | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 11/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | C03568 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 363L00000X | C03568 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | C03568 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 2084P0800X | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | CK1085 | 01 | CT | RR MEDICARE | OTHER |