Provider Demographics
NPI:1427007848
Name:MIDSTATE MEDICAL CENTER
Entity Type:Organization
Organization Name:MIDSTATE MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP CFO
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:BOISVERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-545-0585
Mailing Address - Street 1:P.O. BOX 4131
Mailing Address - Street 2:
Mailing Address - City:YALESVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06492-1481
Mailing Address - Country:US
Mailing Address - Phone:203-284-1340
Mailing Address - Fax:203-265-4557
Practice Address - Street 1:435 LEWIS AVENUE
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:203-694-8200
Practice Address - Fax:860-696-6035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QE0002X, 282N00000X, 363LN0000X
CT0070282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care HospitalGroup - Single Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025078Medicaid
CT004025078Medicaid