Provider Demographics
NPI:1811155849
Name:STATE OF CONNECTICUT HEALTH CENTER
Entity type:Organization
Organization Name:STATE OF CONNECTICUT HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAFRENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-679-7503
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT - DOWLING SOUTH
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:263 FARMINGTON AVE
Practice Address - Street 2:OB/GYN HBP GROUP
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030-0001
Practice Address - Country:US
Practice Address - Phone:860-679-7503
Practice Address - Fax:860-679-1610
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF CONNECTICUT HEALTH CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-27
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT500HBX134CT02OtherANTHEM BLUE CROSS
CT500HBX134CT01OtherANTHEM BLUE CROSS
CT500HBX134CT03OtherANTHEM BLUE CROSS