Healthcare Provider Details

I. General information

NPI: 1437334851
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2008
Last Update Date: 09/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

481 GOLD STAR HWY SUITE 100
GROTON CT
06340-6702
US

IV. Provider business mailing address

575 MAIN ST FL 2 ATTN: CREDENTIALING DPT
MIDDLETOWN CT
06457-2845
US

V. Phone/Fax

Practice location:
  • Phone: 860-446-8858
  • Fax: 860-405-2140
Mailing address:
  • Phone: 860-347-6971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0261
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0261
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0261
License Number StateCT

VIII. Authorized Official

Name: MS. BAIN PATRIE
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 860-347-6971