NPIMap

Organization Active NPI

Mystic Medical Associates LLC

  • Primary Care Clinic/Center
  • Mystic, CT
National Provider Identifier
1972954477
Registry record updated Mar 21, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
Legal business name
MYSTIC MEDICAL ASSOCIATES LLC
Practice address
12 Roosevelt Ave
Second Floor
Mystic, CT 06355-2809
Phone
(860) 245-4126
Fax
(860) 245-4128
NPI assigned
Jun 27, 2016
Last updated
Mar 21, 2024By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Mar 21, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Christopher J Anderson, MSN FNP-CNPI 1669889820
Title
Aprn
Phone
(860) 245-4126

Authorized official NPPES reports the official by name only. The link goes to the one practitioner with that name whose NPPES practice address or phone number is this organization’s.

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Addiction (Substance Use Disorder) CounselorGroup: 193200000X MULTI-SPECIALTY GROUP 101YA0400X
Primary Care Clinic/Center 261QP2300X Primary

Addresses

Primary practice location

12 Roosevelt Ave
Second Floor
Mystic, CT 06355-2809

Mailing address

495 Gold Star Hwy Ste 112
Groton, CT 06340-6229
Phone (860) 245-4126

Other practice location 1

230 S Main St.
Suite #2
Cheshire, CT 06410-0641
Phone (860) 245-4126

National Provider Directory

National Provider Directory

Locations

12 Roosevelt Ave
Ste 2
Mystic, CT 06355
Phone (860) 245-4126

Practitioners & affiliated clinicians

Practitioners 5

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1466985600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1710979200000",
    "number": "1972954477",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "495 GOLD STAR HWY STE 112",
            "city": "GROTON",
            "state": "CT",
            "postal_code": "063406229",
            "telephone_number": "860-245-4126",
            "fax_number": "860-245-4128"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "12 ROOSEVELT AVE",
            "address_2": "SECOND FLOOR",
            "city": "MYSTIC",
            "state": "CT",
            "postal_code": "063552809",
            "telephone_number": "860-245-4126",
            "fax_number": "860-245-4128"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "230 S Main St.",
            "address_2": "Suite #2",
            "address_purpose": "LOCATION",
            "city": "Cheshire",
            "state": "CT",
            "postal_code": "064100641",
            "country_code": "US",
            "telephone_number": "860-245-4126",
            "fax_number": "877-927-0171",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "organization_name": "MYSTIC MEDICAL ASSOCIATES LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2016-06-27",
        "last_updated": "2024-03-21",
        "certification_date": "2024-03-21",
        "status": "A",
        "authorized_official_last_name": "ANDERSON",
        "authorized_official_first_name": "CHRISTOPHER",
        "authorized_official_middle_name": "J",
        "authorized_official_title_or_position": "APRN",
        "authorized_official_telephone_number": "860-245-4126",
        "authorized_official_credential": "MSN FNP-C"
    },
    "taxonomies": [
        {
            "code": "101YA0400X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Counselor, Addiction (Substance Use Disorder)",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "261QP2300X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Primary Care",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Mystic, CT

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 21, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.