Basic Information
| Provider Information | |||||||||
| NPI: | 1336122100 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNIVERSITY OF CONNECTICUT HEALTH CENTER | ||||||||
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| OtherOrganizationName: | DERMATOPATHOLOGY LABORATORY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606797503 | ||||||||
| FaxNumber: | 8606791610 | ||||||||
| Practice Location | |||||||||
| Address1: | 21 SOUTH RD | ||||||||
| Address2: | DERMATOPATHOLOGY LABORATORY | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060322482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606794600 | ||||||||
| FaxNumber: | 8606791248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/25/2005 | ||||||||
| LastUpdateDate: | 11/17/2015 | ||||||||
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| AuthorizedOfficialLastName: | LAFRENIERE | ||||||||
| AuthorizedOfficialFirstName: | DENIS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8606797503 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 291U00000X | 021687 | CT | Y | Laboratories | Clinical Medical Laboratory |
ID Information
| ID | Type | State | Issuer | Description | 1216878 | 05 | CT | MEDICAID |