Basic Information
| Provider Information | |||||||||
| NPI: | 1598795122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SAINT MARY'S HOSPITAL INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | INPATIENT PSYCH EXEMPT UNIT | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 56 FRANKLIN ST | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067061221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037096000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 01/16/2019 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 8607144396 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRINITY HEALTH OF NEW ENGLAND CORPORATION, INC. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0055 | CT | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 19B | 01 | CT | ANTHEM BC BS IP PSYCH | OTHER | IR0800 | 01 | CT | HEALTHNET PROV NO. | OTHER | 004041760 | 05 | CT | MEDICAID | H01112 | 01 | CT | OXFORD PROV ID NO. | OTHER |