Basic Information
| Provider Information | |||||||||
| NPI: | 1477888055 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WINDHAM COMMUNITY MEMORIAL HOSPITAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 112 MANSFIELD AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIMANTIC | ||||||||
| State: | CT | ||||||||
| PostalCode: | 062262045 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032841340 | ||||||||
| FaxNumber: | 2032654557 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2009 | ||||||||
| LastUpdateDate: | 10/15/2009 | ||||||||
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| AuthorizedOfficialLastName: | PAPADAKOS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | N | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 8604566848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | CT | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 004041828 | 05 | CT | MEDICAID |