Basic Information
| Provider Information | |||||||||
| NPI: | 1528269131 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHWEST COMMUNITY HEALTH CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 46 ALBION ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066052602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
| FaxNumber: | 2033306008 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 ALBION ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066052602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033306000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2007 | ||||||||
| LastUpdateDate: | 05/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | HAROON | ||||||||
| AuthorizedOfficialFirstName: | NAILA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2033306000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | 0032 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Dental |
ID Information
| ID | Type | State | Issuer | Description | 004236122 | 05 | CT | MEDICAID |