Healthcare Provider Details

I. General information

NPI: 1396795951
Provider Name (Legal Business Name): JEFFERSON RADIOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2006
Last Update Date: 06/12/2026
Certification Date: 06/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 SEYMOUR ST
HARTFORD CT
06102-8000
US

IV. Provider business mailing address

1260 SILAS DEANE HWY STE 104
WETHERSFIELD CT
06109-4363
US

V. Phone/Fax

Practice location:
  • Phone: 860-289-3375
  • Fax: 860-290-4108
Mailing address:
  • Phone: 860-289-3375
  • Fax: 860-290-4108

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207U00000X
TaxonomyNuclear Medicine Physician
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number
License Number StateNULL
# 6
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: BLAKE G GRAVES
Title or Position: SR VP RCM
Credential:
Phone: 312-919-8317