Provider Demographics
NPI:1740219625
Name:CONNECTICUT PATHOLOGY GROUP PC
Entity Type:Organization
Organization Name:CONNECTICUT PATHOLOGY GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF
Authorized Official - Prefix:DR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-344-6174
Mailing Address - Street 1:PO BOX 1590
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06506-1590
Mailing Address - Country:US
Mailing Address - Phone:203-397-8000
Mailing Address - Fax:203-389-1540
Practice Address - Street 1:28 CRESCENT ST
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-3654
Practice Address - Country:US
Practice Address - Phone:860-344-6174
Practice Address - Fax:860-344-6062
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016547207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0077315OtherCIGNA GRP#
CT4053021Medicaid
CT4832OtherCONNECTICARE GROUP#
CT500HBL066CT01OtherBCBS GROUP#
CT0039758OtherAETNA/USHC GRP#
CT4053021Medicaid
CT=========OtherOXFORD GRP#