Provider Demographics
NPI:1053480293
Name:JOHNSON MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:JOHNSON MEMORIAL HOSPITAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROOSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:413-748-9335
Mailing Address - Street 1:201 CHESTNUT HILL RD
Mailing Address - Street 2:
Mailing Address - City:STAFFORD SPRINGS
Mailing Address - State:CT
Mailing Address - Zip Code:06076-4005
Mailing Address - Country:US
Mailing Address - Phone:860-684-4251
Mailing Address - Fax:
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-4251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRINITY HEALTH - NEW ENGLAND, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-11-06
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT00722084P0800X, 282N00000X
273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes273R00000XHospital UnitsPsychiatric Unit
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4024980Medicaid
CT4041687Medicaid
CT4041687Medicaid