Basic Information
Provider Information
NPI: 1386637742
EntityType: 2
ReplacementNPI:  
OrganizationName: SAINT RAPHAEL MR CENTER
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
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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
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
261QM1200X  Y Ambulatory Health Care FacilitiesClinic/CenterMagnetic Resonance Imaging (MRI)

ID Information
IDTypeStateIssuerDescription
00408889605CT MEDICAID


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