Provider Demographics
NPI:1114062114
Name:MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP EAST HAMPTON
Entity Type:Organization
Organization Name:MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP EAST HAMPTON
Other - Org Name:FAMILY PRACTICE GROUP EAST HAMPTON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLERIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-358-4821
Mailing Address - Street 1:90 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3649
Mailing Address - Country:US
Mailing Address - Phone:860-358-6394
Mailing Address - Fax:860-358-6094
Practice Address - Street 1:42 E HIGH ST
Practice Address - Street 2:
Practice Address - City:EAST HAMPTON
Practice Address - State:CT
Practice Address - Zip Code:06424-1099
Practice Address - Country:US
Practice Address - Phone:860-344-6394
Practice Address - Fax:860-344-6748
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLESEX HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-20
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X, 207QG0300X, 207V00000X, 208000000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00727Medicare ID - Type UnspecifiedMEDICARE GRP #