Provider Demographics
NPI:1902891070
Name:MYSTIC MEDICAL GROUP, PC
Entity Type:Organization
Organization Name:MYSTIC MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MARCH
Authorized Official - Last Name:BLUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-572-8911
Mailing Address - Street 1:200 SANDY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MYSTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06355-1720
Mailing Address - Country:US
Mailing Address - Phone:860-572-8911
Mailing Address - Fax:860-572-7758
Practice Address - Street 1:200 SANDY HOLLOW RD
Practice Address - Street 2:
Practice Address - City:MYSTIC
Practice Address - State:CT
Practice Address - Zip Code:06355-1720
Practice Address - Country:US
Practice Address - Phone:860-572-8911
Practice Address - Fax:860-572-7758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-15
Last Update Date:2009-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004002861Medicaid
CT004002861Medicaid