Provider Demographics
NPI:1093750150
Name:DEPAUL HEALTH SERVICES CORPORATION
Entity Type:Organization
Organization Name:DEPAUL HEALTH SERVICES CORPORATION
Other - Org Name:SAINT RAPHAEL HEALTHCARE SYSTEM HAMDEN SURGERY CENTER, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:DIANA
Authorized Official - Middle Name:T
Authorized Official - Last Name:ELLISON
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CASC
Authorized Official - Phone:203-288-2555
Mailing Address - Street 1:2080 WHITNEY AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HAMDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06518-3600
Mailing Address - Country:US
Mailing Address - Phone:203-288-2555
Mailing Address - Fax:203-288-8048
Practice Address - Street 1:2080 WHITNEY AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:HAMDEN
Practice Address - State:CT
Practice Address - Zip Code:06518-3600
Practice Address - Country:US
Practice Address - Phone:203-288-2555
Practice Address - Fax:203-288-8048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0266261QA1903X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4096640001Medicare NSC