Provider Demographics
NPI:1023191467
Name:WINDHAM COMMUNITY MEMORIAL HOSPITAL, INC.
Entity Type:Organization
Organization Name:WINDHAM COMMUNITY MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF FINANCE
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACKIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-425-8755
Mailing Address - Street 1:112 MANSFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-2045
Mailing Address - Country:US
Mailing Address - Phone:860-425-8755
Mailing Address - Fax:860-885-6492
Practice Address - Street 1:112 MANSFIELD AVE
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-2045
Practice Address - Country:US
Practice Address - Phone:860-456-6752
Practice Address - Fax:203-265-4557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-21
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208M00000X, 282N00000X, 363LN0000X
CT0061261QC1500X, 261QE0002X, 261QP2000X, 261QR0200X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes282N00000XHospitalsGeneral Acute Care Hospital
No208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Multi-Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity HealthGroup - Multi-Specialty
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency CareGroup - Multi-Specialty
No261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical TherapyGroup - Multi-Specialty
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025110Medicaid
CTH055902OtherHEALTHNET
CT004041828Medicaid
CO0014138OtherAETNA
CT0465969015OtherCIGNA
CTTRICAREOther35175
CTH01661OtherOXFORD
CT022OtherBLUE CROSS
CT070021Medicare ID - Type Unspecified
CT004041828Medicaid