1801805403 NPI number — CONNECTICUT VASCULAR SURGICAL ASSOCIATES, PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801805403 NPI number — CONNECTICUT VASCULAR SURGICAL ASSOCIATES, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CONNECTICUT VASCULAR SURGICAL ASSOCIATES, 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:
1801805403
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 KINGS HWY E
Provider Second Line Business Mailing Address:
SUITE 112
Provider Business Mailing Address City Name:
FAIRFIELD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06825-4867
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-382-1900
Provider Business Mailing Address Fax Number:
203-382-0019

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 BEARD SAWMILL RD STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06484-6150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-922-7870
Provider Business Practice Location Address Fax Number:
203-922-7872
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BLATTMAN
Authorized Official First Name:
SETH
Authorized Official Middle Name:
BARAK
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
203-922-7870

Provider Taxonomy Codes

  • Taxonomy code: 2086S0129X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004198489 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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