1225011927 NPI number — CONNECTICUT SURGICAL GROUP, PC

Table of content: (NPI 1225011927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225011927 NPI number — CONNECTICUT SURGICAL GROUP, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT SURGICAL GROUP, PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225011927
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/11/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17 TALCOTT NOTCH RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARMINGTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06032-1818
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-947-0616
Provider Business Mailing Address Fax Number:
860-524-8643

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1260 SILAS DEANE HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WETHERSFIELD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06109-4362
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-547-0614
Provider Business Practice Location Address Fax Number:
860-524-2655
Provider Enumeration Date:
11/28/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MCKELL
Authorized Official First Name:
DOUGLAS
Authorized Official Middle Name:
C
Authorized Official Title or Position:
CHIEF ADMINISTRATIVE OFFICER
Authorized Official Telephone Number:
860-524-4326

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 50CONNSURCT01 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 004139350 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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