Organization
JEFFERSON RADIOLOGY, PC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
BLAKE G GRAVES (SR VP RCM)
(312) 919-8317
Entity
Organization
Contact information
Practice address
80 SEYMOUR ST, HARTFORD, CT 06102-8000
(860) 289-3375
(860) 290-4108
Mailing address
1260 SILAS DEANE HWY STE 104, WETHERSFIELD, CT 06109-4363
(860) 289-3375
(860) 290-4108
Taxonomy
Speciality
Code
Description
License number
State
207U00000X
Nuclear Medicine Physician
—
—
2085B0100X
Body Imaging Physician
—
—
2085N0700X
Neuroradiology Physician
—
—
2085R0202X
Diagnostic Radiology Physician
Primary
—
—
2085R0204X
Vascular & Interventional Radiology Physician
—
—
363AM0700X
Medical Physician Assistant
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
004000295
—
CT
01
—
669045
CONNECTICARE
CT
05
—
9704507
—
MA
01
—
A2516306
OXFORD
CT
01
—
NY108137
WELLCARE/PREFERRED ONE
CT
Enumeration date
05/12/2006
Last updated
06/12/2026
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