Provider Demographics
NPI:1518269091
Name:CONNECTICUT VALLEY RADIOLOGY, PC
Entity Type:Organization
Organization Name:CONNECTICUT VALLEY RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PICHETTE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-522-1101
Mailing Address - Street 1:19 WOODLAND ST
Mailing Address - Street 2:SUITE 15
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105-2372
Mailing Address - Country:US
Mailing Address - Phone:860-522-1101
Mailing Address - Fax:860-549-7092
Practice Address - Street 1:19 WOODLAND ST
Practice Address - Street 2:SUITE 15
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06105-2372
Practice Address - Country:US
Practice Address - Phone:860-522-1101
Practice Address - Fax:860-549-7092
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-03
Last Update Date:2010-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody ImagingGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT15MRI0018CT01OtherANTHEM BLUE CROSS AND BLUE SHIEL
CT004187565Medicaid
CT004187565Medicaid