Basic Information
| Provider Information | |||||||||
| NPI: | 1902921380 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CORNELL SCOTT HILL HEALTH CORPORATION | ||||||||
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| OtherOrganizationName: | CORNELL SCOTT HILL HEALTH CORPORATION | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 COLUMBUS AVENUE | ||||||||
| Address2: | CREDENTIALING SPECIALIST | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033174 | ||||||||
| FaxNumber: | 2035036515 | ||||||||
| Practice Location | |||||||||
| Address1: | 400-428 COLUMBUS AVENUE | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065191233 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035033000 | ||||||||
| FaxNumber: | 2035033224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2007 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | SOL | ||||||||
| AuthorizedOfficialMiddleName: | MARIA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 2035033174 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/28/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0804X | 0459 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Child & Adolescent Psychiatry | 261QD0000X | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Dental | 261QF0400X | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QF0400X | N | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) | 261QH0100X | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Health Service | 261QM0801X | CT | N | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) | 291U00000X | CT | N | Laboratories | Clinical Medical Laboratory | 324500000X | SA-0122 | CT | N | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility | 261QF0400X | 0004 | CT | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 004235900 | 05 | CT | MEDICAID | 007228749 | 05 | CT | MEDICAID | 004011813 | 05 | CT | MEDICAID | 004235893 | 05 | CT | MEDICAID | 004235918 | 05 | CT | MEDICAID |