Provider Demographics
NPI:1396795951
Name:JEFFERSON RADIOLOGY, PC
Entity type:Organization
Organization Name:JEFFERSON RADIOLOGY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHARLEE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEBLEU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-321-7026
Mailing Address - Street 1:111 FOUNDERS PLZ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3212
Mailing Address - Country:US
Mailing Address - Phone:860-528-2080
Mailing Address - Fax:860-291-6594
Practice Address - Street 1:85 SEYMOUR ST STE 200
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5509
Practice Address - Country:US
Practice Address - Phone:860-289-3375
Practice Address - Fax:860-783-5733
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-12
Last Update Date:2024-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty
No207U00000XAllopathic & Osteopathic PhysiciansNuclear MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9704507Medicaid
CTNY108137OtherWELLCARE/PREFERRED ONE
CTA2516306OtherOXFORD
CT004000295Medicaid
CT669045OtherCONNECTICARE
CTNY108137OtherWELLCARE/PREFERRED ONE