Basic Information
| Provider Information | |||||||||
| NPI: | 1023191467 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINDHAM COMMUNITY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604258755 | ||||||||
| FaxNumber: | 8608856492 | ||||||||
| Practice Location | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8604566752 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2006 | ||||||||
| LastUpdateDate: | 04/17/2020 | ||||||||
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| AuthorizedOfficialLastName: | MACKIE | ||||||||
| AuthorizedOfficialFirstName: | JANICE | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8604258755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 04/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist | 261QC1500X | 0061 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Community Health | 261QE0002X | 0061 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 261QP2000X | 0061 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Physical Therapy | 261QR0200X | 0061 | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Radiology | 282N00000X | 0061 | CT | N | Hospitals | General Acute Care Hospital | 363LN0000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Neonatal | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 0465969015 | 01 | CT | CIGNA | OTHER | H01661 | 01 | CT | OXFORD | OTHER | TRICARE | 01 | CT | 35175 | OTHER | 0014138 | 01 | CO | AETNA | OTHER | 004041828 | 05 | CT | MEDICAID | H055902 | 01 | CT | HEALTHNET | OTHER | 022 | 01 | CT | BLUE CROSS | OTHER | 004025110 | 05 | CT | MEDICAID |