Provider Demographics
NPI:1568597128
Name:MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP PORTLAND
Entity Type:Organization
Organization Name:MIDDLESEX HOSPITAL DBA FAMILY PRACTICE GROUP PORTLAND
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR VP FINANCR & OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:G
Authorized Official - Last Name:CAPECE
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:860-344-6394
Mailing Address - Street 1:90 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-3649
Mailing Address - Country:US
Mailing Address - Phone:860-344-6394
Mailing Address - Fax:860-344-6748
Practice Address - Street 1:595 MAIN ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:CT
Practice Address - Zip Code:06480-1156
Practice Address - Country:US
Practice Address - Phone:860-344-6394
Practice Address - Fax:860-344-6748
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X, 207QG0300X, 207V00000X, 208000000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Not Answered207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Not Answered207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00727Medicare ID - Type UnspecifiedMEDICARE GRP #