Provider Demographics
NPI:1760408835
Name:SOUTH WINDSOR AMBULATORY CARE CTR INC
Entity Type:Organization
Organization Name:SOUTH WINDSOR AMBULATORY CARE CTR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:M
Authorized Official - Last Name:PETRONE
Authorized Official - Suffix:
Authorized Official - Credentials:RTR
Authorized Official - Phone:860-644-3491
Mailing Address - Street 1:PO BOX 510
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-0510
Mailing Address - Country:US
Mailing Address - Phone:860-644-3491
Mailing Address - Fax:860-644-5744
Practice Address - Street 1:2800 TAMARACK AVENUE
Practice Address - Street 2:SUITE 105
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5539
Practice Address - Country:US
Practice Address - Phone:860-644-3491
Practice Address - Fax:860-644-5744
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2008-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT024303207R00000X
CT24303261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010024303CT01OtherBLUE SHIELD OF CT
GA1751515OtherUNITED HEALTH CARE
CT704554OtherCONNECTICARE
CT80705OtherGREAT WEST
PA7294618OtherCIGNA
CT0V0438OtherHEALTHNET
TX514837OtherAETNA
CTP3592661OtherOXFORD
CT004263612Medicaid
MA427750OtherTUFTS
MA427750OtherTUFTS
B38469Medicare UPIN