Provider Demographics
NPI:1760940035
Name:MIDDLESEX HOSPITAL DBA MIDDLESEX HOSPITAL PHYSICIAN SERVICES
Entity Type:Organization
Organization Name:MIDDLESEX HOSPITAL DBA MIDDLESEX HOSPITAL PHYSICIAN SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ENROLLMENT SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:MARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:PELLERIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-358-4821
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:
Mailing Address - Fax:
Practice Address - Street 1:540 SAYBROOK RD STE 210
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4759
Practice Address - Country:US
Practice Address - Phone:860-358-6875
Practice Address - Fax:860-358-8693
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDDLESEX HOSPITAL DBA MIDDLESEX HOSPITAL PHYSICIAN SERVICES -PMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty