Basic Information
| Provider Information | |||||||||
| NPI: | 1467541805 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT CHILDREN'S MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 282 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605459000 | ||||||||
| FaxNumber: | 8605458979 | ||||||||
| Practice Location | |||||||||
| Address1: | 282 WASHINGTON ST | ||||||||
| Address2: | ASTHMA CENTER - HARTFORD SQUARE WEST | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605459000 | ||||||||
| FaxNumber: | 8605458979 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 09/11/2007 | ||||||||
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| AuthorizedOfficialLastName: | CLOUTIER | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8605459442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | 026130 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 026130 | 01 | CT | PHYSICIAN/SURGEON LICENSE | OTHER |