Provider Demographics
NPI:1275933095
Name:CROSSROADS PRIMARY CARE, LLC
Entity Type:Organization
Organization Name:CROSSROADS PRIMARY CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MITHLESH
Authorized Official - Middle Name:
Authorized Official - Last Name:GOVIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-443-4455
Mailing Address - Street 1:196 PARKWAY S
Mailing Address - Street 2:SUITE 304
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-7027
Mailing Address - Fax:860-444-0074
Practice Address - Street 1:196 PARKWAY S
Practice Address - Street 2:SUITE 304
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-440-7525
Practice Address - Fax:860-447-8961
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-28
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207R00000X, 332B00000X, 363LA2200X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD100185103Medicare PIN