1922170786 NPI number — CONNECTICUT SURGICAL GROUP, PC

Table of content: JOSEPH LEE WILDE M.D. (NPI 1972521581)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1922170786 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:
1922170786
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/02/2011
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:
860-524-2626
Provider Business Mailing Address Fax Number:
860-677-5029

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
680 SOUTH MAIN STREET
Provider Second Line Business Practice Location Address:
LOWER LEVEL 2
Provider Business Practice Location Address City Name:
CHESHIRE
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06410-3190
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-238-1241
Provider Business Practice Location Address Fax Number:
203-686-0791
Provider Enumeration Date:
11/15/2006

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: 2085R0204X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 87090 . This is a "AETNA" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 0000S02059 . This is a "CSMS-IPA" 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".
  • Identifier: G384943 . This is a "OXFORD" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 50CONNSURCT01 . This is a "ANTHEM BCBS" identifier , issued by the state of ( CT ) . This identifiers is of the category "OTHER".
  • Identifier: 9781188 , issued by the state of ( MA ) . This identifiers is of the category "MEDICAID".




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