Provider Demographics
NPI:1467514893
Name:CONNECTICUT SURGICAL GROUP, PC
Entity Type:Organization
Organization Name:CONNECTICUT SURGICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-524-4326
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 415
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-246-2071
Mailing Address - Fax:860-524-2650
Practice Address - Street 1:2800 TAMARACK RD
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5539
Practice Address - Country:US
Practice Address - Phone:860-246-2071
Practice Address - Fax:860-524-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2010-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004169711Medicaid
CT87090OtherAETNA GROUP NUMBER
MA9781188Medicaid
CT50CONNSURCT01OtherANTHEM BCBS GROUP NUMBER
CT004201034Medicaid
NY01926310Medicaid
CT004139350Medicaid
CT87090OtherAETNA GROUP NUMBER
MA9781188Medicaid