Provider Demographics
NPI:1942423488
Name:CT CHILDRENS MEDICAL CENTER/BETANCES
Entity Type:Organization
Organization Name:CT CHILDRENS MEDICAL CENTER/BETANCES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC PA
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANN
Authorized Official - Middle Name:THERESE
Authorized Official - Last Name:GORJANC
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:860-525-4640
Mailing Address - Street 1:42 CHARTER OAK AVE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1909
Mailing Address - Country:US
Mailing Address - Phone:860-525-4640
Mailing Address - Fax:860-525-4650
Practice Address - Street 1:42 CHARTER OAK AVE
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1909
Practice Address - Country:US
Practice Address - Phone:860-525-4640
Practice Address - Fax:860-525-4650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00363261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTP91688Medicare UPIN