Provider Demographics
NPI:1205979457
Name:COOK WILLOW CONVALESCENT HOSPITAL, INC.
Entity type:Organization
Organization Name:COOK WILLOW CONVALESCENT HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:860-283-8208
Mailing Address - Street 1:81 HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:CT
Mailing Address - Zip Code:06782-2305
Mailing Address - Country:US
Mailing Address - Phone:860-283-8208
Mailing Address - Fax:860-283-6667
Practice Address - Street 1:81 HILLSIDE AVE
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:CT
Practice Address - Zip Code:06782-2305
Practice Address - Country:US
Practice Address - Phone:860-283-8208
Practice Address - Fax:860-283-6667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT932-C314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT649OtherANTHEM BCBS
CTIV5659OtherHEALTHNET PROVIDER
CTV631P-3901OtherVETERAN AFFAIRS CONTRACT
CT075349Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER