Provider Demographics
NPI:1336122100
Name:UNIVERSITY OF CONNECTICUT HEALTH CENTER
Entity Type:Organization
Organization Name:UNIVERSITY OF CONNECTICUT HEALTH CENTER
Other - Org Name:DERMATOPATHOLOGY LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DENIS
Authorized Official - Middle Name:C
Authorized Official - Last Name:LAFRENIERE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-679-7503
Mailing Address - Street 1:263 FARMINGTON AVE
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-2212
Mailing Address - Country:US
Mailing Address - Phone:860-679-7503
Mailing Address - Fax:860-679-1610
Practice Address - Street 1:21 SOUTH RD
Practice Address - Street 2:DERMATOPATHOLOGY LABORATORY
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-2482
Practice Address - Country:US
Practice Address - Phone:860-679-4600
Practice Address - Fax:860-679-1248
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-25
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT021687291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1216878Medicaid
CT1216878Medicaid
CT690000051Medicare ID - Type UnspecifiedDERMATOPATHOLOGY LAB