Provider Demographics
NPI:1316022718
Name:MIDSTATE MEDICAL CENTER
Entity Type:Organization
Organization Name:MIDSTATE MEDICAL CENTER
Other - Org Name:IP PSYCH
Other - Org Type:Other Name
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:RALPH
Authorized Official - Middle Name:W
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-696-6220
Mailing Address - Street 1:435 LEWIS AVE
Mailing Address - Street 2:
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-2101
Mailing Address - Country:US
Mailing Address - Phone:860-696-6287
Mailing Address - Fax:860-696-6035
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2101
Practice Address - Country:US
Practice Address - Phone:860-696-6287
Practice Address - Fax:860-696-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0070273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT07S017Medicare ID - Type Unspecified