Healthcare Provider Details

I. General information

NPI: 1568724466
Provider Name (Legal Business Name): UNIVERSITY OF CONNECTICUT/CAPITAL AREA HEALTH CONSORTIUM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2012
Last Update Date: 09/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 WOODLAND ST
HARTFORD CT
06105-1207
US

IV. Provider business mailing address

270 FARMINGTON AVE SUITE 352
FARMINGTON CT
06032-1994
US

V. Phone/Fax

Practice location:
  • Phone: 860-714-4212
  • Fax:
Mailing address:
  • Phone: 860-676-1110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: DR. LAURENCE TANNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 860-676-1110