Basic Information
| Provider Information | |||||||||
| NPI: | 1053785832 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CHARTER OAK HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507529 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507529 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/17/2015 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | DONAHUE | ||||||||
| AuthorizedOfficialFirstName: | SHANNON | ||||||||
| AuthorizedOfficialMiddleName: | P. | ||||||||
| AuthorizedOfficialTitleorPosition: | INTERIM CFO | ||||||||
| AuthorizedOfficialTelephone: | 8605507524 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X | 0312 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
ID Information
| ID | Type | State | Issuer | Description | 004236007 | 05 | CT | MEDICAID | 896726 | 01 | CT | WELLCARE | OTHER |