Provider Demographics
NPI:1255487989
Name:SURGICAL ASSOCIATES OF NEW HAVEN, PC
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF NEW HAVEN, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDWARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-772-0650
Mailing Address - Street 1:60 TEMPLE ST
Mailing Address - Street 2:SUITE 5A
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06510-2716
Mailing Address - Country:US
Mailing Address - Phone:203-772-0650
Mailing Address - Fax:203-785-9097
Practice Address - Street 1:60 TEMPLE ST
Practice Address - Street 2:SUITE 5A
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-2716
Practice Address - Country:US
Practice Address - Phone:203-772-0650
Practice Address - Fax:203-785-9097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4058491Medicaid
CTD02468Medicare UPIN
CTG23517Medicare UPIN
CTG99978Medicare UPIN
CTC00164Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
CT4058491Medicaid