Provider Demographics
NPI:1588618185
Name:CANCER CENTER OF CENTRAL CONNECTICUT LLC
Entity Type:Organization
Organization Name:CANCER CENTER OF CENTRAL CONNECTICUT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-621-9316
Mailing Address - Street 1:55 MERIDEN AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06489-3237
Mailing Address - Country:US
Mailing Address - Phone:860-621-9316
Mailing Address - Fax:860-620-5526
Practice Address - Street 1:55 MERIDEN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-3237
Practice Address - Country:US
Practice Address - Phone:860-621-9316
Practice Address - Fax:860-620-5526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-19
Last Update Date:2013-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004178209Medicaid
CT5752740001Medicare NSC
CTC03542Medicare PIN