Provider Demographics
NPI:1902356769
Name:YALE NEW HAVEN HOSPITAL - SRC
Entity Type:Organization
Organization Name:YALE NEW HAVEN HOSPITAL - SRC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN'S ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:OLIVER
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:203-376-9368
Mailing Address - Street 1:208 NEWRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708-1093
Mailing Address - Country:US
Mailing Address - Phone:203-592-1271
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-05
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6667282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital