Provider Demographics
NPI:1497055941
Name:STATE OF CONNECTICUT HEALTH CENTER
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT HEALTH CENTER
Other - Org Name:CORRECTIONAL MANAGED HEALTH CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official - Prefix:MS
Authorized Official - First Name:GAIL
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-679-5536
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:MC 5386
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-5386
Mailing Address - Country:US
Mailing Address - Phone:860-679-5500
Mailing Address - Fax:860-676-3415
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:MC 5386
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-5386
Practice Address - Country:US
Practice Address - Phone:860-679-5500
Practice Address - Fax:860-676-3415
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF CONNECTICUT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-11-01
Last Update Date:2010-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization