Healthcare Provider Details

I. General information

NPI: 1164463840
Provider Name (Legal Business Name): COMMUNITY HEALTH CENTER INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/23/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

635 MAIN ST
MIDDLETOWN CT
06457-2718
US

IV. Provider business mailing address

635 MAIN ST ATTN: CREDENTIALING DEPARTMENT
MIDDLETOWN CT
06457-2718
US

V. Phone/Fax

Practice location:
  • Phone: 860-347-6971
  • Fax: 860-638-6601
Mailing address:
  • Phone: 860-347-6971
  • Fax: 860-638-6601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0392
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0392
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0392
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

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