Provider Demographics
NPI:1902891682
Name:STATE OF CONNECTICUT
Entity Type:Organization
Organization Name:STATE OF CONNECTICUT
Other - Org Name:JOHN DEMPSEY HOSPITAL- SUBPROVIDER
Other - Org Type:Other Name
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 AVENUE
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:860-679-2916
Mailing Address - Fax:860-679-3071
Practice Address - Street 1:263 FARMINGTON AVENUE
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:2005-09-19
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00065273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT07-S036Medicare ID - Type Unspecified