Basic Information
Provider Information | |||||||||
NPI: | 1740539162 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | COMMUNITY HEALTH CENTER INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 575 MAIN ST 2ND FLOOR | ||||||||
Address2: | ATTN: CREDENTIALING DEPT | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064572845 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603476971 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 263 MAIN ST | ||||||||
Address2: | 2ND FLOOR | ||||||||
City: | OLD SAYBROOK | ||||||||
State: | CT | ||||||||
PostalCode: | 064752326 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603884433 | ||||||||
FaxNumber: | 8603884434 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2012 | ||||||||
LastUpdateDate: | 08/30/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLINTER | ||||||||
AuthorizedOfficialFirstName: | MARGARET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | SVP/CLINICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 8603476971 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | APRN PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | 0055 | CT | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 004236354 | 05 | CT |   | MEDICAID |