Healthcare Provider Details

I. General information

NPI: 1023191467
Provider Name (Legal Business Name): WINDHAM COMMUNITY MEMORIAL HOSPITAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2006
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

IV. Provider business mailing address

112 MANSFIELD AVE
WILLIMANTIC CT
06226-2045
US

V. Phone/Fax

Practice location:
  • Phone: 860-456-6752
  • Fax: 203-265-4557
Mailing address:
  • Phone: 860-425-8755
  • Fax: 860-885-6492

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number0061
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code261QE0002X
TaxonomyEmergency Care Clinic/Center
License Number0061
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number0061
License Number StateCT
# 5
Primary TaxonomyN
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number0061
License Number StateCT
# 6
Primary TaxonomyN
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number0061
License Number StateCT
# 7
Primary TaxonomyN
Taxonomy Code363LN0000X
TaxonomyNeonatal Nurse Practitioner
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number
License Number State

VIII. Authorized Official

Name: MS. JANICE MACKIE
Title or Position: VP OF FINANCE
Credential:
Phone: 860-425-8755