Basic Information
| Provider Information | |||||||||
| NPI: | 1932123569 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHNSON MEMORIAL HOSPITAL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 201 CHESTNUT HILL RD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD SPRINGS | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060764005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606844251 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 CHESTNUT HILL ROAD | ||||||||
| Address2: | |||||||||
| City: | STAFFORD SPRINGS | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060760860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606844251 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 10/26/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROSENBERG | ||||||||
| AuthorizedOfficialFirstName: | STUART | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8606848235 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TRINITY HEALTH - NEW ENGLAND, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | 0072 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 282N00000X | 0072 | CT | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4024980 | 05 | CT | MEDICAID | 4041687 | 05 | CT | MEDICAID |