Basic Information
| Provider Information | |||||||||
| NPI: | 1952591851 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COMMUNITY HEALTH CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 575 MAIN ST FL 2 | ||||||||
| Address2: | ATTN: CREDENTIALING DEPT | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
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| Practice Location | |||||||||
| Address1: | 675 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064572718 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603476971 | ||||||||
| FaxNumber: | 8603437379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2007 | ||||||||
| LastUpdateDate: | 05/21/2012 | ||||||||
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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 | 101YA0400X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 103TC0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0804X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 213E00000X | N | 193200000X MULTI-SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004236354 | 05 | CT | MEDICAID | 004236346 | 05 | CT | MEDICAID | 004236338 | 05 | CT | MEDICAID |