1144366493 NPI number — STATE OF CONNECTICUT

Table of content: (NPI 1144366493)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144366493 NPI number — STATE OF CONNECTICUT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF CONNECTICUT
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
STS COTTAGE 1
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144366493
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 872
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488-0901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-586-2602
Provider Business Mailing Address Fax Number:
203-586-2700

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1461 SOUTH BRITAIN ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488-1139
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-586-2000
Provider Business Practice Location Address Fax Number:
203-586-2700
Provider Enumeration Date:
01/30/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HARVEY
Authorized Official First Name:
EUGENE
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
203-586-2466

Provider Taxonomy Codes

  • Taxonomy code: 315P00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: C00793 . This is a "MEDICARE ID - TYPE UNSPECIFIED" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 006782264 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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