NPIMap

Organization Active NPI

Staywell Health Care, Inc.

  • Family Medicine Physician
  • Waterbury, CT
National Provider Identifier
1033366240
Registry record updated Jan 9, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
Legal business name
STAYWELL HEALTH CARE, INC.
Practice address
95 Thomaston Ave
Waterbury, CT 06702-1007
Phone
(203) 756-8021
Fax
(203) 805-4913
NPI assigned
Aug 20, 2008
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Jan 9, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Donald Thompson
Title
President
Phone
(203) 756-8021

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 207Q00000X Primary
Federally Qualified Health Center (FQHC) 261QF0400X

Addresses

Primary practice location

95 Thomaston Ave
Waterbury, CT 06702-1007

Mailing address

80 Phoenix Ave Ste 201
Waterbury, CT 06702-1418
Phone (203) 756-8021

Other names 1

  • Staywell Health Care Inc/G.W. Mental/Auth Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in CT2 enrollments

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
O20070608000584 CT Part A Provider - Federally Qualified Health Center (FQHC) 6305750480 1 other NPI on this enrollment
Practice locations: Waterbury, CT
O20140829002189 CT Part A Provider - Federally Qualified Health Center (FQHC) 6305750480 1 other NPI on this enrollment
This NPI is an additional NPI on the enrollment
Practice locations: Waterbury, CT

Federally qualified health center certification: CCN 071836

Legal name
STAYWELL HEALTH CARE INC.
Doing business as
STAYWELL HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Jul 24, 2007
Last certification
Jul 24, 2007
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 11, 1994 in CT
Enrollment address
95 Thomaston Ave
Waterbury, CT 67021007

Federally qualified health center certification: CCN 071908

Legal name
STAYWELL HEALTH CARE INC.
Doing business as
STAYWELL HEALTH CENTER
Certification status
Active
Provider type (POS)
Federally qualified health center
Participating since
Nov 17, 2014
Last certification
Nov 17, 2014
Ownership / control type
For profit – corporation
Organization structure
CorporationNon-profit
Incorporated
Dec 11, 1994 in CT
Enrollment address
402 E Main St
Waterbury, CT 67021701

Other NPIs with the same Medicare PAC ID 6

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Other NPIs on the same Medicare enrollment 2

NPIs listed together on one Medicare enrollment, typically parts of the same organization.

National Provider Directory

National Provider Directory

Locations

1302 S Main St
Waterbury, CT 06706
Phone (203) 597-9044

Ownership & related parties

All disclosed owners & managing parties 19

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Amit Patel Individual Corporate DirectorDental Director Sep 1, 2001
Thomas Johnson Individual Corporate OfficerBoard Member Oct 15, 2012
Carolyn a Highsmith Individual Corporate OfficerBoard Member Feb 1, 2010
Sandra J Sorel-Leduc Individual Corporate OfficerBoard Member Mar 1, 2004
Beverly a Lyons Individual Corporate DirectorDirector of Behavioral Health Sep 26, 2006
Lule G Tracey Individual Corporate DirectorChief Financial Officer Feb 1, 1999
Corporate DirectorCfo Feb 1, 1999
Christine S Bianchi Individual Corporate DirectorChief Development Officer Jul 1, 2011
W-2 Managing EmployeeChief Development Officer Jul 1, 2011
Lynn Tripp Individual Corporate DirectorHR Director Oct 1, 2018
W-2 Managing EmployeeHR Director Oct 1, 2018
Donald J Thompson Individual Corporate Officer Sep 11, 1989
Mark L Briggs Individual Corporate OfficerVice Chair, Board of Directors Feb 6, 2006
Corporate OfficerVice Chair Board of Directors Feb 6, 2006
June Lewis Individual W-2 Managing EmployeeOffice Manager Oct 30, 1981
W-2 Managing EmployeeOffice Manager Sep 29, 1980
Abby Dibattista Individual W-2 Managing EmployeeBilling Manager Jan 1, 2014
Naga S Yalamachili Individual Corporate DirectorInformation Systems Director Jul 1, 2006
Christopher M King Individual Corporate OfficerBoard Member Jan 8, 2007
Sunil B Dcunha Individual Corporate DirectorCmo Jul 1, 2004
Migdalia Rosario Individual Corporate OfficerChairperson Jan 1, 1999
Arlene M Arias Individual Corporate Officer Nov 7, 2005
Judy a Acosta Individual Corporate OfficerBoard Member Consumer Aug 13, 2012
Karen Moody Individual W-2 Managing EmployeeOffice Manager Jun 30, 2006

Owners & managing parties with NPI records 3

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

Practitioners & affiliated clinicians

Practitioners 43

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 43

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1219190400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1578528000000",
    "number": "1033366240",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "80 PHOENIX AVE STE 201",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067021418",
            "telephone_number": "203-756-8021",
            "fax_number": "203-596-9038"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "95 THOMASTON AVE",
            "city": "WATERBURY",
            "state": "CT",
            "postal_code": "067021007",
            "telephone_number": "203-756-8021",
            "fax_number": "203-805-4913"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "STAYWELL HEALTH CARE, INC.",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-20",
        "last_updated": "2020-01-09",
        "certification_date": "2020-01-09",
        "status": "A",
        "authorized_official_last_name": "THOMPSON",
        "authorized_official_first_name": "DONALD",
        "authorized_official_title_or_position": "PRESIDENT",
        "authorized_official_telephone_number": "203-756-8021",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Family Medicine",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "261QF0400X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Federally Qualified Health Center (FQHC)",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Staywell Health Care Inc/G.W. Mental/Auth",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Staywell Health Care Inc/G.W. Mental/Auth",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Waterbury, CT

Sources for this page

Verify at the official NPI Registry.