Basic Information
Provider Information | |||||||||
NPI: | 1205039260 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HILL HEALTH CORPORATION | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NORTHSIDE | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 7720 | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065190720 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035033205 | ||||||||
FaxNumber: | 2035033455 | ||||||||
Practice Location | |||||||||
Address1: | 226 DIXWELL AVE | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065113456 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2035033205 | ||||||||
FaxNumber: | 2035033455 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2007 | ||||||||
LastUpdateDate: | 01/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | GONZALEZ | ||||||||
AuthorizedOfficialFirstName: | SOL | ||||||||
AuthorizedOfficialMiddleName: | MARIA | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
AuthorizedOfficialTelephone: | 2035033174 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | C0264 | CT | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
ID | Type | State | Issuer | Description | 004235918 | 05 | CT |   | MEDICAID |