Provider Demographics
| NPI: | 1952591851 |
|---|---|
| Name: | COMMUNITY HEALTH CENTER INC |
| Entity Type: | Organization |
| Organization Name: | COMMUNITY HEALTH CENTER INC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CREDENTIALING SPECIALIST |
| Authorized Official - Prefix: | MS |
| Authorized Official - First Name: | BAIN |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | PATRIE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | |
| Authorized Official - Phone: | 860-347-6971 |
| Mailing Address - Street 1: | 575 MAIN ST FL 2 |
| Mailing Address - Street 2: | ATTN: CREDENTIALING DEPT |
| Mailing Address - City: | MIDDLETOWN |
| Mailing Address - State: | CT |
| Mailing Address - Zip Code: | 06457-2845 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 860-347-6971 |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 675 MAIN ST |
| Practice Address - Street 2: | |
| Practice Address - City: | MIDDLETOWN |
| Practice Address - State: | CT |
| Practice Address - Zip Code: | 06457-2718 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 860-347-6971 |
| Practice Address - Fax: | 860-343-7379 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2007-07-26 |
| Last Update Date: | 2012-05-21 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 261QF0400X | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | |
| No | 101YA0400X | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | Group - Multi-Specialty |
| No | 103TC0700X | Behavioral Health & Social Service Providers | Psychologist | Clinical | Group - Multi-Specialty |
| No | 1041C0700X | Behavioral Health & Social Service Providers | Social Worker | Clinical | Group - Multi-Specialty |
| No | 106H00000X | Behavioral Health & Social Service Providers | Marriage & Family Therapist | Group - Multi-Specialty | |
| No | 1223G0001X | Dental Providers | Dentist | General Practice | Group - Multi-Specialty |
| No | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207V00000X | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2084P0800X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | Group - Multi-Specialty |
| No | 2084P0804X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | Group - Multi-Specialty |
| No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CT | 004236354 | Medicaid | |
| CT | 004236346 | Medicaid | |
| CT | 004236338 | Medicaid | |
| CT | 071839 | Medicare PIN | |
| CT | 004236338 | Medicaid | |
| CT | 071842 | Medicare PIN | |
| CT | 071840 | Medicare PIN | |
| CT | 004236346 | Medicaid | |
| CT | 071862 | Medicare PIN | |
| CT | 071843 | Medicare PIN | |
| CT | 071841 | Medicare PIN | |
| CT | 071844 | Medicare PIN | |
| CT | 071850 | Medicare PIN | |
| 071802 | Medicare PIN |
