Provider Demographics
NPI:1457382855
Name:MADISON RADIOLOGY PC
Entity Type:Organization
Organization Name:MADISON RADIOLOGY PC
Other - Org Name:OLD LYME RADIOLOGY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:
Authorized Official - Last Name:WALBY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-245-7351
Mailing Address - Street 1:2 SAMSON ROCK DR
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-9998
Mailing Address - Country:US
Mailing Address - Phone:203-245-7351
Mailing Address - Fax:203-245-8838
Practice Address - Street 1:2 SAMSON ROCK DR
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:CT
Practice Address - Zip Code:06443-9998
Practice Address - Country:US
Practice Address - Phone:203-245-7351
Practice Address - Fax:203-245-8838
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MADISON RADIOLOGY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2008-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT02643261QR0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0206XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mammography