Provider Demographics
NPI:1245295401
Name:GREATER WATERBURY IMAGING CENTER LIMITED PARTNERSHIP
Entity type:Organization
Organization Name:GREATER WATERBURY IMAGING CENTER LIMITED PARTNERSHIP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:S
Authorized Official - Last Name:KELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-282-6000
Mailing Address - Street 1:PO BOX 150473
Mailing Address - Street 2:DEPT. 335
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06115-0473
Mailing Address - Country:US
Mailing Address - Phone:949-282-6000
Mailing Address - Fax:
Practice Address - Street 1:68 ROBBINS ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2613
Practice Address - Country:US
Practice Address - Phone:203-573-7674
Practice Address - Fax:203-573-6255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-19
Last Update Date:2011-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes293D00000XLaboratoriesPhysiological Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT360000010Medicare PIN