Basic Information
Provider Information | |||||||||
NPI: | 1710121389 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WINTERMUTE | ||||||||
FirstName: | RICHARD | ||||||||
MiddleName: | L. | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 510 CLINTON AVE | ||||||||
Address2: | SOUTHWEST COMMUNITY HEALTH CENTER, INC | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CT | ||||||||
PostalCode: | 066051701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033364000 | ||||||||
FaxNumber: | 2033822954 | ||||||||
Practice Location | |||||||||
Address1: | 46 ALBION ST | ||||||||
Address2: | SOUTHWEST COMMUNITY HEALTH CENTER, INC | ||||||||
City: | BRIDGEPORT | ||||||||
State: | CT | ||||||||
PostalCode: | 066052602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2033323155 | ||||||||
FaxNumber: | 2033306008 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2009 | ||||||||
LastUpdateDate: | 08/08/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 52219 | CT | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 004236130 | 05 | CT |   | MEDICAID |