Provider Demographics
NPI:1356361315
Name:MIDSTATE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:MIDSTATE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:F
Authorized Official - Last Name:TILDEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-694-8750
Mailing Address - Street 1:435 LEWIS AVENUE
Mailing Address - Street 2:MIDSTATE MEDICAL GROUP, PC
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451
Mailing Address - Country:US
Mailing Address - Phone:203-694-8750
Mailing Address - Fax:
Practice Address - Street 1:435 LEWIS AVENUE
Practice Address - Street 2:MIDSTATE MEDICAL GROUP, PC
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451
Practice Address - Country:US
Practice Address - Phone:203-694-8750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2008-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTN/A208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03589Medicare PIN