Organization
MIDSTATE MEDICAL GROUP, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
RALPH BECKER (VICE PRESIDENT, FINANCE)
(860) 545-7602
Entity
Organization
Contact information
Practice address
98 MAIN ST STE 300, SOUTHINGTON, CT 06489-2500
(203) 694-5580
(860) 620-0446
Mailing address
98 MAIN ST STE 300, SOUTHINGTON, CT 06489-2500
(203) 694-5580
(860) 620-0446
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
—
—
207R00000X
Internal Medicine Physician
Primary
—
—
207RH0003X
Hematology & Oncology Physician
—
—
207RS0010X
Sports Medicine (Internal Medicine) Physician
—
—
207X00000X
Orthopaedic Surgery Physician
—
—
207Y00000X
Otolaryngology Physician
—
—
2084N0400X
Neurology Physician
—
—
208600000X
Surgery Physician
—
—
208G00000X
Thoracic Surgery (Cardiothoracic Vascular Surgery) Physician
—
—
363A00000X
Physician Assistant
—
—
363L00000X
Nurse Practitioner
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004260022
—
CT
Enumeration date
07/06/2006
Last updated
08/24/2012
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