Provider Demographics
NPI:1316050925
Name:EVERGREEN IMAGING CENTER, LLC
Entity type:Organization
Organization Name:EVERGREEN IMAGING CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:MCCONVILLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-533-3429
Mailing Address - Street 1:2800 TAMARACK AVE
Mailing Address - Street 2:SUITE 002
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074
Mailing Address - Country:US
Mailing Address - Phone:860-533-4600
Mailing Address - Fax:860-533-4601
Practice Address - Street 1:2800 TAMARACK AVE
Practice Address - Street 2:SUITE 002
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074
Practice Address - Country:US
Practice Address - Phone:860-533-4600
Practice Address - Fax:860-533-4601
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-16
Last Update Date:2008-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004261351Medicaid
CT004261351Medicaid