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  5. MYSTIC MEDICAL GROUP, P.C.

MYSTIC MEDICAL GROUP, P.C.

Company Details

Entity Name: MYSTIC MEDICAL GROUP, P.C.
Jurisdiction: Connecticut
Legal type: Stock
Citizenship: Domestic
Status: Dissolved
Date Formed: 02 Apr 1981
Date of dissolution: 31 Dec 2018
Business ALEI: 0116403
Annual report due: 30 Apr 2019
Business address: 270 MONTAUK AVE., NEW LONDON, CT, 06320
ZIP code: 06320
County: New London
Place of Formation: CONNECTICUT
Total authorized shares: 500
E-Mail: sclarke@mysticmedicalgroup.com

form 5500

Plan Name Plan Year EIN/PN Received Sponsor Total number of participants
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2017 061039154 2018-09-12 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2018-09-12
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-09-12
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2017 061039154 2018-02-20 MYSTIC MEDICAL GROUP, P.C. 19
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2018-02-16
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2018-02-16
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2016 061039154 2017-03-02 MYSTIC MEDICAL GROUP, P.C. 17
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2017-03-01
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2017-03-01
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2015 061039154 2016-03-18 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2016-03-17
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2016-03-17
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2014 061039154 2015-03-18 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2015-03-18
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
Role Employer/plan sponsor
Date 2015-03-18
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2013 061039154 2014-03-13 MYSTIC MEDICAL GROUP, P.C. 14
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2014-03-13
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2012 061039154 2013-02-26 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Signature of
Role Plan administrator
Date 2013-02-13
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2011 061039154 2012-03-27 MYSTIC MEDICAL GROUP, P.C. 17
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Plan administrator’s name and address
Administrator’s EIN 061039154
Plan administrator’s name MYSTIC MEDICAL GROUP, P.C.
Plan administrator’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355
Administrator’s telephone number 8605728911

Signature of
Role Plan administrator
Date 2012-03-26
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2010 061039154 2011-04-07 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Plan administrator’s name and address
Administrator’s EIN 061039154
Plan administrator’s name MYSTIC MEDICAL GROUP, P.C.
Plan administrator’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355
Administrator’s telephone number 8605728911

Signature of
Role Plan administrator
Date 2011-04-07
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature
MYSTIC MEDICAL GROUP, P.C. PROFIT-SHARING PLAN 2009 061039154 2010-09-01 MYSTIC MEDICAL GROUP, P.C. 16
File View Page
Three-digit plan number (PN) 002
Effective date of plan 1991-04-01
Business code 621111
Sponsor’s telephone number 8605728911
Plan sponsor’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355

Plan administrator’s name and address
Administrator’s EIN 061039154
Plan administrator’s name MYSTIC MEDICAL GROUP, P.C.
Plan administrator’s address 200 SANDY HOLLOW ROAD, MYSTIC, CT, 06355
Administrator’s telephone number 8605728911

Signature of
Role Plan administrator
Date 2010-09-01
Name of individual signing THOMAS BLUM
Valid signature Filed with authorized/valid electronic signature

Agent

Name Role
SUISMAN, SHAPIRO, WOOL, BRENNAN, GRAY & GREENBERG,P.C. Agent

Officer

Name Role Business address Residence address
JAMES SCARLES Officer 270 MONTAUK AVE, NEW LONDON, CT, 06320, United States 17 HEATH ST, MYSTIC, CT, 06355, United States
ROSEMARY BONTEMPI Officer 270 MONTAUK AVE, NEW LONDON, CT, 06320, United States 1 PEPPER BOX RD., WATERFORD, CT, 06385, United States
WARREN L. FIELDS Officer 270 MONTAUK AVE., NEW LONDON, CT, 06320, United States 20 MYSTIC HILL RD, MYSTIC, CT, 06355, United States

Filing

Filing number Filing date Effective date Filing category Filing type Report year
0006253823 2018-10-02 2018-12-31 Dissolution Certificate of Dissolution No data
0006133754 2018-03-22 No data Annual Report Annual Report 2018
0005818130 2017-04-13 No data Annual Report Annual Report 2017
0005540981 2016-04-14 No data Annual Report Annual Report 2016
0005311984 2015-04-09 No data Annual Report Annual Report 2015
0005071533 2014-03-26 No data Annual Report Annual Report 2014
0004833344 2013-04-04 No data Annual Report Annual Report 2013
0004579743 2012-04-18 No data Annual Report Annual Report 2012
0004512939 2011-04-08 No data Annual Report Annual Report 2011
0004182296 2010-04-26 No data Annual Report Annual Report 2010

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Date of last update: 25 Nov 2024

Sources: Connecticut's Official State Website

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