Provider Demographics
NPI:1336279058
Name:MHS PRIMARY CARE, INC
Entity Type:Organization
Organization Name:MHS PRIMARY CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-358-3005
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:860-358-4820
Mailing Address - Fax:860-358-8661
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3654
Practice Address - Country:US
Practice Address - Phone:860-358-4820
Practice Address - Fax:860-358-8661
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-06
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT023007207Q00000X, 207R00000X
207QS0010X
CT000621363A00000X
CT002921363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports 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
CT04201084Medicaid
CT04173259Medicaid
CT008073532Medicaid
CT04181343Medicaid
CT04173259Medicaid
CTC02243Medicare PIN
CTC02139Medicare PIN