Basic Information
| Provider Information | |||||||||
| NPI: | 1912165945 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | STATE OF CONNECTICUT HEALTH CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | RADIOLOGY HBP GROUP | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | PROVIDER ENROLLMENT - DOWLING SOUTH | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060302212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606797503 | ||||||||
| FaxNumber: | 8606791610 | ||||||||
| Practice Location | |||||||||
| Address1: | 263 FARMINGTON AVE | ||||||||
| Address2: | RADIOLOGY HBP GROUP | ||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060300001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606797503 | ||||||||
| FaxNumber: | 8606791610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2008 | ||||||||
| LastUpdateDate: | 06/15/2012 | ||||||||
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| AuthorizedOfficialLastName: | LAFRENIERE | ||||||||
| AuthorizedOfficialFirstName: | DENIS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8606797503 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | STATE OF CONNECTICUT HEALTH CENTER | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 500HBX121CT01 | 01 | CT | ANTHEM BLUE CROSS | OTHER |