Basic Information
| Provider Information | |||||||||
| NPI: | 1912156845 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT KIDNEY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 INDIAN RIVER RD | ||||||||
| Address2: | SUITE A5 | ||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064773649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037991252 | ||||||||
| FaxNumber: | 2037993252 | ||||||||
| Practice Location | |||||||||
| Address1: | 240 INDIAN RIVER RD | ||||||||
| Address2: | SUITE A5 | ||||||||
| City: | ORANGE | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064773649 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037991252 | ||||||||
| FaxNumber: | 2037991252 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2008 | ||||||||
| LastUpdateDate: | 01/05/2011 | ||||||||
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| AuthorizedOfficialLastName: | ONOFRIO | ||||||||
| AuthorizedOfficialFirstName: | MAUREEN | ||||||||
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| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2037991252 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONNECTICUT KIDNEY CENTER, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | CT | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 008002231 | 05 | CT | MEDICAID |