Provider Demographics
NPI:1578518999
Name:MIDSTATE RADIOLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:MIDSTATE RADIOLOGY ASSOCIATES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-949-2700
Mailing Address - Street 1:101 N PLAINS INDUSTRIAL RD
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2360
Mailing Address - Country:US
Mailing Address - Phone:203-949-2700
Mailing Address - Fax:203-949-2712
Practice Address - Street 1:435 LEWIS AVE
Practice Address - Street 2:
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451
Practice Address - Country:US
Practice Address - Phone:203-949-2700
Practice Address - Fax:203-949-2712
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-24
Last Update Date:2019-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02342Medicare UPIN