Provider Demographics
NPI:1972857282
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:JOHN DEMPSEY HOSPITAL-HEMOPHILIA CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:BIANCAMANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-679-1145
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-5355
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-5355
Practice Address - Country:US
Practice Address - Phone:860-679-2916
Practice Address - Fax:860-679-3071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2012-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00065282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4041968Medicaid
CTXXXXXXXXXOtherTRICARE/CHAMPUS
CT07-0036OtherMEDICARE ID-TYPE UNSPECIFIED