Provider Demographics
NPI:1023371275
Name:HOSPITAL OF SAINT RAPHAEL
Entity type:Organization
Organization Name:HOSPITAL OF SAINT RAPHAEL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLEW
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:203-784-8750
Mailing Address - Street 1:1294 CHAPEL ST
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4515
Mailing Address - Country:US
Mailing Address - Phone:203-784-8750
Mailing Address - Fax:
Practice Address - Street 1:1294 CHAPEL ST
Practice Address - Street 2:2ND FLOOR
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4515
Practice Address - Country:US
Practice Address - Phone:203-784-8750
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-22
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty