Provider Demographics
NPI:1467541805
Name:CONNECTICUT CHILDREN'S MEDICAL CENTER
Entity Type:Organization
Organization Name:CONNECTICUT CHILDREN'S MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CLOUTIER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-545-9442
Mailing Address - Street 1:282 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-3322
Mailing Address - Country:US
Mailing Address - Phone:860-545-9000
Mailing Address - Fax:860-545-8979
Practice Address - Street 1:282 WASHINGTON ST
Practice Address - Street 2:ASTHMA CENTER - HARTFORD SQUARE WEST
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-3322
Practice Address - Country:US
Practice Address - Phone:860-545-9000
Practice Address - Fax:860-545-8979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-12
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0261302080P0214X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT026130OtherPHYSICIAN/SURGEON LICENSE