Provider Demographics
NPI:1497937411
Name:CHILD & ADOLESCENT HEALTH CARE
Entity Type:Organization
Organization Name:CHILD & ADOLESCENT HEALTH CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JANE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUDOLPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-574-4747
Mailing Address - Street 1:179 ROSELAND AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06710
Mailing Address - Country:US
Mailing Address - Phone:203-574-4747
Mailing Address - Fax:203-574-2251
Practice Address - Street 1:179 ROSELAND AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06710
Practice Address - Country:US
Practice Address - Phone:203-574-4747
Practice Address - Fax:203-574-2251
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000431208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4049987Medicaid