Healthcare Provider Details

I. General information

NPI: 1093760431
Provider Name (Legal Business Name): DIAGNOSTIC IMAGING SERVICES OF CT, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2006
Last Update Date: 08/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

565 LONG HILL RD
GROTON CT
06340-4166
US

IV. Provider business mailing address

101 N PLAINS INDUSTRIAL RD
WALLINGFORD CT
06492-2360
US

V. Phone/Fax

Practice location:
  • Phone: 203-949-2700
  • Fax: 203-949-2712
Mailing address:
  • Phone: 203-949-2700
  • Fax: 203-949-2712

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: GARY DEE
Title or Position: OWNER
Credential: MD
Phone: 203-949-2700