Basic Information
| Provider Information | |||||||||
| NPI: | 1952649097 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YALE UNIVERSITY | ||||||||
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| OtherOrganizationName: | YALE THERAPEUTIC RADIOLOGY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9805 | ||||||||
| Address2: | 300 GEORGE ST 6TH FLR | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065360805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037852140 | ||||||||
| FaxNumber: | 2037856414 | ||||||||
| Practice Location | |||||||||
| Address1: | 20 YORK ST | ||||||||
| Address2: | |||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065103220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032002100 | ||||||||
| FaxNumber: | 2032002180 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2013 | ||||||||
| LastUpdateDate: | 01/24/2013 | ||||||||
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| AuthorizedOfficialLastName: | DESS-SANTORO | ||||||||
| AuthorizedOfficialFirstName: | MARIANNE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF REVENUE OFFICE | ||||||||
| AuthorizedOfficialTelephone: | 2037854120 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology |
No ID Information.