1124004031 NPI number — CONNECTICUT RADIOLOGY ASSOCIATES PC

Table of content: DUANE EDMUND ELLSWORTH D.O. (NPI 1821222456)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124004031 NPI number — CONNECTICUT RADIOLOGY ASSOCIATES PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT RADIOLOGY ASSOCIATES PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124004031
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 30231
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06150-0231
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-927-0002
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 SEYMOUR AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DERBY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06418-1343
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-735-8769
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/22/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MARGOLIES
Authorized Official First Name:
LAURIE
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
800-927-0002

Provider Taxonomy Codes

  • Taxonomy code: 2085R0202X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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