Basic Information
| Provider Information | |||||||||
| NPI: | 1265540967 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAY KIMBALL HEALTHCARE, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609285341 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 POMFRET ST | ||||||||
| Address2: | |||||||||
| City: | PUTNAM | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062601836 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8609286541 | ||||||||
| FaxNumber: | 8609285341 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2006 | ||||||||
| LastUpdateDate: | 11/17/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIAMOND | ||||||||
| AuthorizedOfficialFirstName: | ANNEMARIE | ||||||||
| AuthorizedOfficialMiddleName: | H | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 8609286541 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DAY KIMBALL HEALTHCARE, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 176B00000X | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Midwife | 207Q00000X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RH0003X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RP1001X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease | 207V00000X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207VE0102X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Reproductive Endocrinology | 208000000X | 0043 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 363L00000X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363LP0200X | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | 261QC1500X | 0043 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Community Health |
ID Information
| ID | Type | State | Issuer | Description | 004024931 | 05 | CT | MEDICAID |