Basic Information
| Provider Information | |||||||||
| NPI: | 1053477075 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE HOSPITAL OF CENTRAL CONNECTICUT AT NEW BRITAIN GENERAL AND BRADLEY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE HOSPITAL OF CENTRAL CONNECTICUT | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060522016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602245011 | ||||||||
| FaxNumber: | 8602245740 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060522016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602245011 | ||||||||
| FaxNumber: | 8602245740 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/28/2006 | ||||||||
| LastUpdateDate: | 03/04/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAVICAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8602245723 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/04/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 004041950 | 01 | CT | BEH HLTH PARTNERSHIP INPT | OTHER | 95G | 01 | CT | ANTHEM BEH HEALTH | OTHER | 004025243 | 01 | CT | SAGA OUTPT | OTHER | 00428753 | 05 | NY | MEDICAID | 092132700 | 05 | FL | MEDICAID | H02258 | 01 | CT | OXFORD INSURANCE | OTHER | 4025243 | 05 | CT | MEDICAID | 344791 | 01 | CT | WELLCARE MEDICARE | OTHER | IV1010 | 01 | CT | HEALTHNET INSURANCE | OTHER | 004025243 | 01 | CT | BEH HLTH PARTNERSHIP OP | OTHER | 95G | 01 | CT | BC FAMILYPLAN | OTHER | CTGA001016 | 01 | CT | ADV BEH HEALTH | OTHER | 4041950 | 05 | CT | MEDICAID | 900050 | 01 | CT | CONNECTICARE INSURANCE | OTHER | 004041950 | 01 | CT | SAGA INPT | OTHER | 95B | 01 | CO | BLUECROSS | OTHER |