Basic Information
| Provider Information | |||||||||
| NPI: | 1902356769 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | YALE NEW HAVEN HOSPITAL - SRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 208 NEWRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067081093 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035921271 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2016 | ||||||||
| LastUpdateDate: | 10/05/2016 | ||||||||
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| AuthorizedOfficialLastName: | OLIVER | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PHYSICIAN'S ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2033769368 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PA-C | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 6667 | CT | Y | Hospitals | General Acute Care Hospital |
No ID Information.