Healthcare Provider Details

I. General information

NPI: 1841592466
Provider Name (Legal Business Name): CORNELL SCOTT HILL HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2010
Last Update Date: 10/05/2022
Certification Date: 10/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 CAMPBELL AVENUE WEST HAVEN HEALTH CENTER
WEST HAVEN CT
06516-7307
US

IV. Provider business mailing address

PO BOX 7720 CREDENTIALING SPECIALISTH
NEW HAVEN CT
06519-1233
US

V. Phone/Fax

Practice location:
  • Phone: 203-503-3400
  • Fax: 203-931-3759
Mailing address:
  • Phone: 203-503-3174
  • Fax: 203-503-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number0518
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: SOL MARIA GONZALEZ
Title or Position: CREDENTIALING SPECIALIST
Credential:
Phone: 203-503-3174