Basic Information
Provider Information | |||||||||
NPI: | 1386637742 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SAINT RAPHAEL MR CENTER | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 11 LUNAR DR | ||||||||
Address2: |   | ||||||||
City: | WOODBRIDGE | ||||||||
State: | CT | ||||||||
PostalCode: | 065252320 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2032989113 | ||||||||
FaxNumber: | 2032989106 | ||||||||
Practice Location | |||||||||
Address1: | 330 ORCHARD ST | ||||||||
Address2: |   | ||||||||
City: | NEW HAVEN | ||||||||
State: | CT | ||||||||
PostalCode: | 065114417 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037894120 | ||||||||
FaxNumber: | 2037895183 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/31/2005 | ||||||||
LastUpdateDate: | 02/01/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PROTOPAPAS | ||||||||
AuthorizedOfficialFirstName: | ZENON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 2037894120 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Magnetic Resonance Imaging (MRI) |
ID Information
ID | Type | State | Issuer | Description | 004088896 | 05 | CT |   | MEDICAID |