Basic Information
Provider Information | |||||||||
NPI: | 1760426969 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT MARY'S HOSPITAL, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | ST. MARY'S HOSPITAL CORPORATION | ||||||||
OtherOrganizationType: | 4 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 56 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067061221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037096000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 56 FRANKLIN ST | ||||||||
Address2: |   | ||||||||
City: | WATERBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 067061221 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037096000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/16/2006 | ||||||||
LastUpdateDate: | 01/16/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HARRIS | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | M | ||||||||
AuthorizedOfficialTitleorPosition: | REGIONAL DIRECTOR OF REIMBURSEMENT | ||||||||
AuthorizedOfficialTelephone: | 8607144396 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRINITY HEALTH OF NEW ENGLAND CORPORATION, INC. | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0055 | CT | Y |   | Hospitals | General Acute Care Hospital |   |
ID Information
ID | Type | State | Issuer | Description | 004025060 | 05 | CT |   | MEDICAID | H01112 | 01 | CT | OXFORD PROV NO. | OTHER | 019 | 01 | CT | ANTHEM BLUE CROSS BS | OTHER | IR0800 | 01 | CT | HEALTHNET PROV NO. | OTHER | 004041760 | 05 | CT |   | MEDICAID |