Provider Demographics
NPI:1457399198
Name:MANCHESTER MEMORIAL HOSPITAL
Entity Type:Organization
Organization Name:MANCHESTER MEMORIAL HOSPITAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:KARL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-646-1222
Mailing Address - Street 1:71 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4131
Mailing Address - Country:US
Mailing Address - Phone:860-646-1222
Mailing Address - Fax:
Practice Address - Street 1:71 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4131
Practice Address - Country:US
Practice Address - Phone:860-646-1222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN CONNECTICUT HEALTH NETWORK
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-06-03
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0048261QE0002X, 282N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282N00000XHospitalsGeneral Acute Care Hospital
No261QE0002XAmbulatory Health Care FacilitiesClinic/CenterEmergency Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4041885Medicaid
CT4025177Medicaid
CT4025177Medicaid