Provider Demographics
NPI:1003001850
Name:MAIN MEDICAL-MYSTIC, LLC
Entity Type:Organization
Organization Name:MAIN MEDICAL-MYSTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ROY
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:MAIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-536-1666
Mailing Address - Street 1:23 CLARA DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1959
Mailing Address - Country:US
Mailing Address - Phone:860-536-1666
Mailing Address - Fax:860-536-9770
Practice Address - Street 1:23 CLARA DR
Practice Address - Street 2:SUITE 201
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1959
Practice Address - Country:US
Practice Address - Phone:860-536-1666
Practice Address - Fax:860-536-9770
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-13
Last Update Date:2007-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT031865207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02861Medicare PIN
CTB30093Medicare UPIN