CORNELL SCOTT HILL HEALTH CORPORATION

Provider Demographics

• NPI: 1902921380
• Name: CORNELL SCOTT HILL HEALTH CORPORATION
• Entity Type: Organization
• Organization Name: CORNELL SCOTT HILL HEALTH CORPORATION
• Other - Org Name: CORNELL SCOTT HILL HEALTH CORPORATION
• Other - Org Type: Former Legal Business Name
• Authorized Official - Title/Position: CREDENTIALING SPECIALIST
• Authorized Official - First Name: SOL
• Authorized Official - Middle Name: MARIA
• Authorized Official - Last Name: GONZALEZ
• Authorized Official - Phone: 203-503-3174
• Mailing Address - Street 1: 400 COLUMBUS AVENUE
• Mailing Address - Street 2: CREDENTIALING SPECIALIST
• Mailing Address - City: NEW HAVEN
• Mailing Address - State: CT
• Mailing Address - Zip Code: 06519-1223
• Mailing Address - Country: US
• Mailing Address - Phone: 203-503-3174
• Mailing Address - Fax: 203-503-6515
• Practice Address - Street 1: 400-428 COLUMBUS AVENUE
• Practice Address - City: NEW HAVEN
• Practice Address - State: CT
• Practice Address - Zip Code: 06519-1233
• Practice Address - Country: US
• Practice Address - Phone: 203-503-3000
• Practice Address - Fax: 203-503-3224
• EIN: <UNAVAIL>
• Is Organization Subpart?: No
• Enumeration Date: 2007-03-21
• Last Update Date: 2022-07-21

Provider Licenses

State	License ID	Taxonomies
CT	0459	2084P0804X
CT		261QD0000X, 261QF0400X, 261QH0100X, 261QM0801X, 291U00000X
CT	0004	261QF0400X
		261QF0400X
CT	SA-0122	324500000X

Provider Taxonomies

Primary?	Code	Type	Classification	Specialization	Group
Yes	261QF0400X	Ambulatory Health Care Facilities	Clinic/Center	Federally Qualified Health Center (FQHC)
No	2084P0804X	Allopathic & Osteopathic Physicians	Psychiatry & Neurology	Child & Adolescent Psychiatry	Group - Multi-Specialty
No	261QD0000X	Ambulatory Health Care Facilities	Clinic/Center	Dental
No	261QH0100X	Ambulatory Health Care Facilities	Clinic/Center	Health Service
No	261QM0801X	Ambulatory Health Care Facilities	Clinic/Center	Mental Health (Including Community Mental Health Center)
No	291U00000X	Laboratories	Clinical Medical Laboratory
No	324500000X	Residential Treatment Facilities	Substance Abuse Rehabilitation Facility

Provider Identifiers

State	Identifier ID	ID Type	Issuer
CT	004235900	Medicaid
CT	007228749	Medicaid
CT	004011813	Medicaid
CT	004235893	Medicaid
CT	004235918	Medicaid
CT	007228749	Medicaid