Provider Demographics
NPI:1972954477
Name:MYSTIC MEDICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:MYSTIC MEDICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:J
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MSN FNP-C
Authorized Official - Phone:860-245-4126
Mailing Address - Street 1:495 GOLD STAR HWY STE 112
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6229
Mailing Address - Country:US
Mailing Address - Phone:860-245-4126
Mailing Address - Fax:860-245-4128
Practice Address - Street 1:12 ROOSEVELT AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-2809
Practice Address - Country:US
Practice Address - Phone:860-245-4126
Practice Address - Fax:860-245-4128
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty