Basic Information
| Provider Information | |||||||||
| NPI: | 1790227536 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLETOWN MEDICAL PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 MALTESE DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8453438741 | ||||||||
| Practice Location | |||||||||
| Address1: | 111 MALTESE DR | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109402115 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453424774 | ||||||||
| FaxNumber: | 8453438741 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2016 | ||||||||
| LastUpdateDate: | 11/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | PHILLIPS | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE ASSIST CEO | ||||||||
| AuthorizedOfficialTelephone: | 8453424774 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | W11581 | 01 | NY | MEDICARE | OTHER |