Provider Demographics
NPI: | 1881956514 |
---|---|
Name: | MID STATE MD, LLC |
Entity type: | Organization |
Organization Name: | MID STATE MD, LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEMBER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | JOHN |
Authorized Official - Middle Name: | J |
Authorized Official - Last Name: | BORKOWSKI |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 860-346-8657 |
Mailing Address - Street 1: | 85 CHURCH ST STE 500 |
Mailing Address - Street 2: | |
Mailing Address - City: | MIDDLETOWN |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06457-3647 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-346-8657 |
Mailing Address - Fax: | 860-347-9554 |
Practice Address - Street 1: | 85 CHURCH ST STE 500 |
Practice Address - Street 2: | |
Practice Address - City: | MIDDLETOWN |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06457-3647 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-346-8657 |
Practice Address - Fax: | 860-347-9554 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2012-06-08 |
Last Update Date: | 2012-06-08 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
CT | 18705 | 208200000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Single Specialty |