Basic Information
| Provider Information | |||||||||
| NPI: | 1730137753 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | GAYLORD HOSPITAL, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GAYLORD HOSPITAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | GAYLORD FARM RD. | ||||||||
| Address2: | PO BOX 400 | ||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2032943294 | ||||||||
| Practice Location | |||||||||
| Address1: | GAYLORD FARM RD. | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06492 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032842800 | ||||||||
| FaxNumber: | 2032943294 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/04/2006 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HOLLAND | ||||||||
| AuthorizedOfficialFirstName: | STEPHEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CMO | ||||||||
| AuthorizedOfficialTelephone: | 2032842800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation | 282E00000X | Y | Hospitals | Long Term Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 000070029 | 05 | CT | MEDICAID | 004025284 | 05 | CT | MEDICAID |