Provider Demographics
NPI:1053785832
Name:CHARTER OAK HEALTH CENTER
Entity type:Organization
Organization Name:CHARTER OAK HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CFO
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:P
Authorized Official - Last Name:DONAHUE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-550-7524
Mailing Address - Street 1:21 GRAND ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-1541
Mailing Address - Country:US
Mailing Address - Phone:860-550-7500
Mailing Address - Fax:860-550-7529
Practice Address - Street 1:21 GRAND ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-1541
Practice Address - Country:US
Practice Address - Phone:860-550-7500
Practice Address - Fax:860-550-7529
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-17
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0312261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236007Medicaid
CT896726OtherWELLCARE
CT07-1819Medicare PIN