Basic Information
| Provider Information | |||||||||
| NPI: | 1720250624 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTEGRATED HEALTH SERVICES, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 763 BURNSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061082791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602919787 | ||||||||
| FaxNumber: | 8602912392 | ||||||||
| Practice Location | |||||||||
| Address1: | 869 FORBES ST | ||||||||
| Address2: | |||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061181958 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606225340 | ||||||||
| FaxNumber: | 8606225342 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2008 | ||||||||
| LastUpdateDate: | 11/22/2013 | ||||||||
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| AuthorizedOfficialLastName: | POERIO | ||||||||
| AuthorizedOfficialFirstName: | DEBORAH | ||||||||
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| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8602919787 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | APRN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QD0000X | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 008001955 | 05 | CT | MEDICAID | 008002608 | 05 | CT | MEDICAID |