Provider Demographics
NPI:1205894375
Name:MIDDLESEX GASTROENTEROLOGY ASSOCIATES, LLC
Entity type:Organization
Organization Name:MIDDLESEX GASTROENTEROLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:
Authorized Official - Last Name:RICCI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-347-4620
Mailing Address - Street 1:410 SAYBROOK ROAD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4747
Mailing Address - Country:US
Mailing Address - Phone:860-347-4620
Mailing Address - Fax:860-346-9687
Practice Address - Street 1:410 SAYBROOK ROAD
Practice Address - Street 2:SUITE 201
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4747
Practice Address - Country:US
Practice Address - Phone:860-347-4620
Practice Address - Fax:860-346-9687
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-01
Last Update Date:2023-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT025965207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00275Medicare UPIN