Provider Demographics
NPI:1154342335
Name:STAYWELL HEALTH CARE, INC.
Entity type:Organization
Organization Name:STAYWELL HEALTH CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMPSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-756-8021
Mailing Address - Street 1:80 PHOENIX AVE
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06702-1418
Mailing Address - Country:US
Mailing Address - Phone:203-756-8021
Mailing Address - Fax:203-596-9038
Practice Address - Street 1:80 PHOENIX AVE
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06702-1418
Practice Address - Country:US
Practice Address - Phone:203-756-8021
Practice Address - Fax:203-596-9038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT207Q00000X
208000000X, 261QF0400X, 261QH0100X
CT0360261QD0000X
CT0736261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDentalGroup - Multi-Specialty
No261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004235984Medicaid
CT004235968Medicaid
CT004235976Medicaid
CT071826Medicare Oscar/Certification
CTC00415Medicare PIN