Basic Information
| Provider Information | |||||||||
| NPI: | 1912193376 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SAINT RAPHAEL FACULTY PHYSICIANS II | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 ALEXANDER DR | ||||||||
| Address2: | |||||||||
| City: | GUILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064375031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8476096661 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037893464 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2007 | ||||||||
| LastUpdateDate: | 09/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2037893464 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 37688 | 01 | CT | PO BOX | OTHER |