MEDICARE: NEW HAVEN PUBLIC SCHOOLS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP2300X	Primary Care Clinic/Center	PENDING	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0V1232	OTHER	CT	HEALTH NET PROVIDER ID
2	166185	OTHER	CT	VALUE OPTIONS PROVIDER NO

General Provider Information

NPI Number	:	1063532596
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NEW HAVEN PUBLIC SCHOOLS

Provider Business Mailing Address
First Line	:	54 MEADOW ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-1783
Country	:	US
Telephone Number	:	203-946-8969
Fax Number	:	203-946-8664

Provider Business Practice Location Address
First Line	:	54 MEADOW ST
Second Line	:
City	:	NEW HAVEN
State	:	CT
Zip	:	06519-1783
Country	:	US
Telephone Number	:	203-946-8969
Fax Number	:	203-946-8664

Authorized Official
Title or Position	:	DIRECTOR
Name	:	MR. CARLOS CEBALLOS
Credential	:	PA, M.P.H.
Telephone Number	:	203-234-9317

Provider Enumeration Date	:	03/29/2007
Last Update Date	:	07/13/2007

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Directions to “NEW HAVEN PUBLIC SCHOOLS ” Practice Location

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