Healthcare Provider Details

I. General information

NPI: 1457382855
Provider Name (Legal Business Name): MADISON RADIOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2006
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 SAMSON ROCK DR
MADISON CT
06443-9998
US

IV. Provider business mailing address

2 SAMSON ROCK DR
MADISON CT
06443-9998
US

V. Phone/Fax

Practice location:
  • Phone: 203-245-7351
  • Fax: 203-245-8838
Mailing address:
  • Phone: 203-245-7351
  • Fax: 203-245-8838

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0206X
TaxonomyMammography Clinic/Center
License Number02643
License Number StateCT

VIII. Authorized Official

Name: MS. MARY WALBY
Title or Position: OFFICE MANAGER
Credential:
Phone: 203-245-7351