Provider Demographics
NPI:1689877995
Name:MIDSTATE NEPHROLOGY ASSOCIATES PC
Entity Type:Organization
Organization Name:MIDSTATE NEPHROLOGY ASSOCIATES PC
Other - Org Name:N/A
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SOFIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GUZMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-344-8606
Mailing Address - Street 1:535 SAYBROOK RD STE 5
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4743
Mailing Address - Country:US
Mailing Address - Phone:860-344-8606
Mailing Address - Fax:860-344-8963
Practice Address - Street 1:535 SAYBROOK RD STE 5
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4743
Practice Address - Country:US
Practice Address - Phone:860-344-8606
Practice Address - Fax:860-344-8963
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-06
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4064721Medicaid
CT4064721Medicaid