Provider Demographics
NPI:1275846453
Name:CONNECTICUT IMAGING PARTNERS, LLC
Entity Type:Organization
Organization Name:CONNECTICUT IMAGING PARTNERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAWNEE
Authorized Official - Middle Name:
Authorized Official - Last Name:MOODY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-289-3375
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400 - CREDENTIALING
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-289-3375
Mailing Address - Fax:860-783-5733
Practice Address - Street 1:100 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5446
Practice Address - Country:US
Practice Address - Phone:860-283-3375
Practice Address - Fax:860-783-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004252110Medicaid
CT004252110Medicaid