Provider Demographics
NPI:1366477903
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:DBA CEDARCREST HOSPITAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:ALBERT
Authorized Official - Last Name:CROMPTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-418-6923
Mailing Address - Street 1:525 RUSSELL RD
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111
Mailing Address - Country:US
Mailing Address - Phone:860-666-7681
Mailing Address - Fax:860-666-7675
Practice Address - Street 1:525 RUSSELL RD
Practice Address - Street 2:
Practice Address - City:NEWINGTON
Practice Address - State:CT
Practice Address - Zip Code:06111
Practice Address - Country:US
Practice Address - Phone:860-666-7681
Practice Address - Fax:860-666-7675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283Q00000XHospitalsPsychiatric Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03257Medicare ID - Type UnspecifiedMEDICARE FIRST COAST
CT074009Medicare Oscar/Certification