Healthcare Provider Details

I. General information

NPI: 1154364016
Provider Name (Legal Business Name): MANCHESTER MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 01/26/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 MAIN ST
MANCHESTER CT
06040-4144
US

IV. Provider business mailing address

71 HAYNES ST
MANCHESTER CT
06040-4131
US

V. Phone/Fax

Practice location:
  • Phone: 860-646-1222
  • Fax:
Mailing address:
  • Phone: 860-646-1222
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number0048
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number0048
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License Number0048
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number0048
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number0048
License Number StateCT
# 6
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number0048
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: PETER KARL
Title or Position: CEO
Credential:
Phone: 860-646-1222