Provider Demographics
NPI:1962488981
Name:BRIDGEPORT RADIOLOGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:BRIDGEPORT RADIOLOGICAL ASSOCIATES LLC
Other - Org Name:ADVANCED RADIOLOGY CONSULTANTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:IAN
Authorized Official - Middle Name:
Authorized Official - Last Name:KAROL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-696-6125
Mailing Address - Street 1:1 CORPORATE DR STE 325
Mailing Address - Street 2:
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-6295
Mailing Address - Country:US
Mailing Address - Phone:203-696-3642
Mailing Address - Fax:203-331-9731
Practice Address - Street 1:1 CORPORATE DR STE 325
Practice Address - Street 2:
Practice Address - City:SHELTON
Practice Address - State:CT
Practice Address - Zip Code:06484-6295
Practice Address - Country:US
Practice Address - Phone:203-696-3642
Practice Address - Fax:203-331-9731
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-21
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004045787Medicaid
CTC02748Medicare ID - Type Unspecified