Provider Demographics
NPI:1730311143
Name:COMMUNITY HEALTH CENTER INC
Entity Type:Organization
Organization Name:COMMUNITY HEALTH CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MS
Authorized Official - First Name:BAIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PATRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-347-6971
Mailing Address - Street 1:575 MAIN ST 2ND FLOOR
Mailing Address - Street 2:ATTN: CREDENTIALING DEPARTMENT
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-2718
Mailing Address - Country:US
Mailing Address - Phone:860-347-6971
Mailing Address - Fax:
Practice Address - Street 1:141 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06901-1014
Practice Address - Country:US
Practice Address - Phone:203-969-0802
Practice Address - Fax:203-326-2990
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-18
Last Update Date:2012-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0455261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236354Medicaid
CT004236338Medicaid
CT004236346Medicaid
CT004236354Medicaid