Basic Information
| Provider Information | |||||||||
| NPI: | 1578106951 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT CHILDREN'S MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10 COLUMBUS BLVD | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061061976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8608376325 | ||||||||
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| Practice Location | |||||||||
| Address1: | 282 WASHINGTON ST | ||||||||
| Address2: | |||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061063322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8605459000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/18/2019 | ||||||||
| LastUpdateDate: | 02/25/2020 | ||||||||
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| AuthorizedOfficialLastName: | JACOBSEN | ||||||||
| AuthorizedOfficialFirstName: | RACHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | SENIOR REV CYCLE ANALYST | ||||||||
| AuthorizedOfficialTelephone: | 8608376325 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONNECTICUT CHILDREN'S MEDICAL CENTER | ||||||||
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| NPICertificationDate: | 02/25/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QE0700X | Y | Ambulatory Health Care Facilities | Clinic/Center | End-Stage Renal Disease (ESRD) Treatment |
No ID Information.