1902962905 NPI number — CENTRAL CONNECTICUT RADIATION ONCOLOGY PC

Table of content: (NPI 1902962905)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902962905 NPI number — CENTRAL CONNECTICUT RADIATION ONCOLOGY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CONNECTICUT RADIATION ONCOLOGY 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:
1902962905
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
760 SAYBROOK RD BLDG A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MIDDLETOWN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06457-4785
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-704-0106
Provider Business Mailing Address Fax Number:
860-704-0125

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
536 SAYBROOK RD
Provider Second Line Business Practice Location Address:
MIDDLESEX HOSPITAL CANCER CENTER
Provider Business Practice Location Address City Name:
MIDDLETOWN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-704-0106
Provider Business Practice Location Address Fax Number:
860-704-0125
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
GOLDBERG
Authorized Official First Name:
NEAL
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER PARTNER
Authorized Official Telephone Number:
860-224-5520

Provider Taxonomy Codes

  • Taxonomy code: 207RX0202X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2085R0001X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: CCRO4074712 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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