Provider Demographics
NPI:1588638688
Name:MASONICARE HEALTH CENTER
Entity Type:Organization
Organization Name:MASONICARE HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:JON-PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:VENOIT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-679-5000
Mailing Address - Street 1:22 MASONIC AVE
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-3048
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:22 MASONIC AVE
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-3048
Practice Address - Country:US
Practice Address - Phone:203-679-5900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-15
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0075261Q00000X, 261QA1903X, 261QC1500X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004025425Medicaid
CT0070177Medicaid
CT082OtherBLUE CROSS
CT004014791Medicaid
CT0070177Medicaid
CT070039Medicare Oscar/Certification