Basic Information
| Provider Information | |||||||||
| NPI: | 1730311143 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 MAIN ST 2ND FLOOR | ||||||||
| Address2: | ATTN: CREDENTIALING DEPARTMENT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
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| Practice Location | |||||||||
| Address1: | 141 FRANKLIN ST | ||||||||
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| City: | STAMFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 069011014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2039690802 | ||||||||
| FaxNumber: | 2033262990 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2009 | ||||||||
| LastUpdateDate: | 11/02/2012 | ||||||||
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| AuthorizedOfficialLastName: | PATRIE | ||||||||
| AuthorizedOfficialFirstName: | BAIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 8603476971 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0455 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004236354 | 05 | CT | MEDICAID | 004236338 | 05 | CT | MEDICAID | 004236346 | 05 | CT | MEDICAID |