Basic Information
| Provider Information | |||||||||
| NPI: | 1225154446 | ||||||||
| EntityType: | 2 | ||||||||
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| 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: | 8605507501 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 GRAND ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605507500 | ||||||||
| FaxNumber: | 8605507501 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 02/02/2011 | ||||||||
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| AuthorizedOfficialLastName: | MORRISON | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | SENIOR VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 8605507500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223G0001X | 0312 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | 004235992 | 05 | CT | MEDICAID |