Basic Information
| Provider Information | |||||||||
| NPI: | 1316394638 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROSPECT MANCHESTER HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANCHESTER MEMORIAL HOSPITAL | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606461222 | ||||||||
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| Practice Location | |||||||||
| Address1: | 71 HAYNES ST | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060404131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606461222 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2016 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| AuthorizedOfficialLastName: | ELDERS | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | JON | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 7147881249 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0002X | N | Ambulatory Health Care Facilities | Clinic/Center | Emergency Care | 282N00000X | Y | Hospitals | General Acute Care Hospital |
No ID Information.