Healthcare Provider Details

I. General information

NPI: 1750632659
Provider Name (Legal Business Name): COMMUNITY HEALTH SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2012
Last Update Date: 06/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ALBANY AVE
HARTFORD CT
06120-2508
US

IV. Provider business mailing address

500 ALBANY AVE
HARTFORD CT
06120-2508
US

V. Phone/Fax

Practice location:
  • Phone: 860-249-9625
  • Fax: 860-808-1580
Mailing address:
  • Phone: 860-249-9625
  • Fax: 860-808-1580

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0676
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QD0000X
TaxonomyDental Clinic/Center
License Number0676
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0676
License Number StateCT

VIII. Authorized Official

Name: MS. ANDREA MONTGOMERY
Title or Position: INTERIM CEO
Credential:
Phone: 860-249-9625