Provider Demographics
| NPI: | 1720194053 |
|---|---|
| Name: | PROHEALTH PHYSICIANS PC |
| Entity type: | Organization |
| Organization Name: | PROHEALTH PHYSICIANS PC |
| Other - Org Name: | |
| Other - Org Type: | |
| Authorized Official - Title/Position: | CHIEF MEDICAL OFFICER |
| Authorized Official - Prefix: | DR |
| Authorized Official - First Name: | JENNIFER |
| Authorized Official - Middle Name: | |
| Authorized Official - Last Name: | DONAHUE |
| Authorized Official - Suffix: | |
| Authorized Official - Credentials: | MD |
| Authorized Official - Phone: | 860-284-5207 |
| Mailing Address - Street 1: | 3 FARM GLEN BLVD |
| Mailing Address - Street 2: | PROHEALTH PHYSICIANS |
| Mailing Address - City: | FARMINGTON |
| Mailing Address - State: | CT |
| Mailing Address - Zip Code: | 06032-1981 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | 860-284-5200 |
| Mailing Address - Fax: | 860-409-4077 |
| Practice Address - Street 1: | 3 FARM GLEN BLVD |
| Practice Address - Street 2: | PROHEALTH PHYSICIANS |
| Practice Address - City: | FARMINGTON |
| Practice Address - State: | CT |
| Practice Address - Zip Code: | 06032-1981 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 860-284-5200 |
| Practice Address - Fax: | 860-409-4077 |
| EIN: | <UNAVAIL> |
| Is Organization Subpart?: | No |
| Parent Organization LBN: | |
| Parent Organization TIN: | |
| Enumeration Date: | 2006-08-21 |
| Last Update Date: | 2023-09-29 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization | Group |
|---|---|---|---|---|---|
| Yes | 207Q00000X | Allopathic & Osteopathic Physicians | Family Medicine | Group - Multi-Specialty | |
| No | 207R00000X | Allopathic & Osteopathic Physicians | Internal Medicine | Group - Multi-Specialty | |
| No | 207RG0100X | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | Group - Multi-Specialty |
| No | 207Y00000X | Allopathic & Osteopathic Physicians | Otolaryngology | Group - Multi-Specialty | |
| No | 208000000X | Allopathic & Osteopathic Physicians | Pediatrics | Group - Multi-Specialty | |
| No | 2080P0206X | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Gastroenterology | Group - Multi-Specialty |
| No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | Group - Multi-Specialty |
| No | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Group - Multi-Specialty | |
| No | 363A00000X | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Group - Multi-Specialty | |
| No | 363L00000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Group - Multi-Specialty | |
| No | 363LA2200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | Group - Multi-Specialty |
| No | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | Group - Multi-Specialty |
| No | 363LP0200X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics | Group - Multi-Specialty |
| No | 363LP2300X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care | Group - Multi-Specialty |
| No | 364SA2200X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health | Group - Multi-Specialty |
Provider Identifiers
| State | Identifier ID | ID Type | Issuer |
|---|---|---|---|
| CT | 004171659 | Other | PED MEDICAID |
| CT | 004174439 | Medicaid | |
| CT | 004174421 | Other | FP MEDICAID |
| CT | 004236073 | Other | PT MEDICAID |
| CT | C02126 | Other | MEDICARE PTAN |
