| Name: | Toll Gate Radiology, Inc. |
| Jurisdiction: | Rhode Island |
| Entity type: | Professional Service Corporation |
| Status: | Revoked Entity |
| Date of Organization in Rhode Island: | 01 Oct 1978 (46 years ago) |
| Date of Dissolution: | 13 Aug 2014 (10 years ago) |
| Date of Status Change: | 13 Aug 2014 (10 years ago) |
| Identification Number: | 000010668 |
| ZIP code: | 02886 |
| County: | Kent County |
| Principal Address: | 215 TOLL GATE ROAD, WARWICK, RI, 02886, USA |
| Purpose: | PROFESSIONAL MEDICAL SERVICES |
| NPI | Enumeration Date | Last Update Date | Mailing Address | Practice Location Address | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 1881604940 | 2006-08-09 | 2008-12-16 | 215 TOLL GATE RD, STE 109, WARWICK, RI, 028864458, US | 300 TOLL GATE RD, STE 101A, STE 102, WARWICK, RI, 028864416, US | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
|
|||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Phone | +1 401-738-3100 |
| Fax | 4017388505 |
Authorized person
| Name | DR. ANTHONY G BRUZZESE |
| Role | PRESIDENT |
| Phone | 4017383100 |
Taxonomy
| Taxonomy Code | 2085B0100X - Body Imaging Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085D0003X - Diagnostic Neuroimaging (Radiology) Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085N0700X - Neuroradiology Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085N0904X - Nuclear Radiology Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085P0229X - Pediatric Radiology Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085R0202X - Diagnostic Radiology Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | Yes |
| Taxonomy Code | 2085R0204X - Vascular & Interventional Radiology Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
| Taxonomy Code | 2085U0001X - Diagnostic Ultrasound Physician |
| License Number | RAD0066 |
| State | RI |
| Is Primary | No |
Other Provider Identifiers
| Issuer | MEDICAID |
| Number | 9001570 |
| State | RI |
| Issuer | BCBS KENT HOSP PROVIDER N |
| Number | 1570-5 |
| State | RI |
| Issuer | AETNA OFFICE PROVIDER NO |
| Number | 2188604 |
| State | RI |
| Issuer | NEIGHBORHOOD H PLAN PROVI |
| Number | 2203 |
| State | RI |
| Issuer | UNITED HEALTHCARE |
| Number | 1742251 |
| State | RI |
| Issuer | RAILROAD MEDICARE |
| Number | CD2379 |
| State | RI |
| Issuer | MEDICAID |
| Number | 9001198 |
| State | RI |
| Issuer | BCBS OFFICE PROVIDER NO |
| Number | 1198-5 |
| State | RI |
| Issuer | TUFTS HEALTH PLAN |
| Number | 703058 |
| State | RI |
| Issuer | UNICARE LIFE AND HLTH INS |
| Number | 50356624 |
| State | RI |
| Issuer | AETNA KENT HOSPITAL PROV |
| Number | 5144133 |
| State | RI |
| Issuer | CIGNA |
| Number | 68453 |
| State | RI |
| Plan Name | Plan Year | EIN/PN | Received | Sponsor | Total number of participants | |||||||||||||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| TOLLGATE RADIOLOGY, INC. PROFIT SHARING PLAN RADIOLOGY, INC. PROFIT SHARING PLAN | 2009 | 050356624 | 2011-07-15 | TOLL GATE RADIOLOGY, INC. | 41 | |||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||||||||
| Administrator’s EIN | 050356624 |
| Plan administrator’s name | TOLL GATE RADIOLOGY, INC. |
| Plan administrator’s address | 215 TOLL GATE ROAD, WARWICK, RI, 02886 |
| Administrator’s telephone number | 4017321860 |
Signature of
| Role | Plan administrator |
| Date | 2011-07-15 |
| Name of individual signing | ANTHONY BRUZZESE |
| Valid signature | Filed with authorized/valid electronic signature |
| Name | Role | Address |
|---|---|---|
| JAY M. ELLAS, ESQ. | Agent | 321 SOUTH MAIN STREET, PROVIDENCE, RI, 02903, USA |
| Name | Role | Address |
|---|---|---|
| ANTHONY G BRUZZESE MD | PRESIDENT | 215 TOLL GATE ROAD WARWICK, RI 02886 USA |
| Name | Role | Address |
|---|---|---|
| ANTHONY G BRUZZESE MD | TREASURER | 215 TOLLGATE ROAD WARWICK, RI 02886 USA |
| Name | Role | Address |
|---|---|---|
| ANTHONY G BRUZZESE MD | DIRECTOR | 215 TOLLGATE ROAD WARWICK, RI 02886 USA |
| Number | Name | File Date |
|---|---|---|
| 201444097650 | Revocation Certificate For Failure to File the Annual Report for the Year | 2014-08-13 |
| 201440608670 | Revocation Notice For Failure to File An Annual Report | 2014-06-05 |
| 201440602560 | Registered Office Not Maintained | 2014-06-04 |
| 201439374650 | Revocation Notice For Failure to File An Annual Report | 2014-05-20 |
| 201313073880 | Annual Report | 2013-02-27 |
| 201289694430 | Annual Report | 2012-02-14 |
| 201176298220 | Annual Report | 2011-03-07 |
| 201057400700 | Annual Report | 2010-01-26 |
| 200951966170 | Statement of Change of Registered Office by the Registered Agent | 2009-10-02 |
| 200943038580 | Annual Report | 2009-02-23 |
Date of last update: 05 Oct 2024
Sources: Rhode Island Department of State
