Provider Demographics
NPI:1164649075
Name:MHS PRIMARY CARE
Entity Type:Organization
Organization Name:MHS PRIMARY CARE
Other - Org Name:MADISON FAMILY PHYSICIANS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SERKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-358-4802
Mailing Address - Street 1:28 CRESCENT ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3654
Mailing Address - Country:US
Mailing Address - Phone:860-358-4819
Mailing Address - Fax:860-632-0240
Practice Address - Street 1:1291 BOSTON POST RD
Practice Address - Street 2:SUITE 105
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-3476
Practice Address - Country:US
Practice Address - Phone:203-245-1413
Practice Address - Fax:203-318-0814
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363A00000X, 363LF0000X
CT207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT04173259Medicaid
CTC02326Medicare PIN
CTC02243Medicare PIN