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
StateLicense IDTaxonomies
CT18705208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty