=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083093579
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUE HILLS BEHAVIORAL HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/29/2015
-----------------------------------------------------
Last Update Date | 05/29/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11 S MAIN ST
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-3656
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-852-3860
-----------------------------------------------------
Fax | 860-852-3860
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 52
-----------------------------------------------------
City | MIDDLETOWN
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06457-0052
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-852-3860
-----------------------------------------------------
Fax | 860-852-3860
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PSYCHIATRIST
-----------------------------------------------------
Name | NICK RAMANDI
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 860-852-3860
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | 50282
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------