Healthcare Provider Details

I. General information

NPI: 1902962905
Provider Name (Legal Business Name): CENTRAL CONNECTICUT RADIATION ONCOLOGY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2006
Last Update Date: 02/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

536 SAYBROOK RD MIDDLESEX HOSPITAL CANCER CENTER
MIDDLETOWN CT
06457
US

IV. Provider business mailing address

760 SAYBROOK RD BLDG A
MIDDLETOWN CT
06457-4785
US

V. Phone/Fax

Practice location:
  • Phone: 860-704-0106
  • Fax: 860-704-0125
Mailing address:
  • Phone: 860-704-0106
  • Fax: 860-704-0125

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number
License Number State

VIII. Authorized Official

Name: NEAL B GOLDBERG
Title or Position: OWNER PARTNER
Credential: MD
Phone: 860-224-5520