Provider Demographics
NPI:1497709885
Name:THE CENTER FOR RECONSTRUCTIVE FOOT SURGERY, P.C.
Entity Type:Organization
Organization Name:THE CENTER FOR RECONSTRUCTIVE FOOT SURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:P
Authorized Official - Last Name:JOLLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-229-2807
Mailing Address - Street 1:1 LIBERTY SQ
Mailing Address - Street 2:
Mailing Address - City:NEW BRITAIN
Mailing Address - State:CT
Mailing Address - Zip Code:06051-2637
Mailing Address - Country:US
Mailing Address - Phone:860-229-2807
Mailing Address - Fax:860-229-2812
Practice Address - Street 1:1 LIBERTY SQ
Practice Address - Street 2:
Practice Address - City:NEW BRITAIN
Practice Address - State:CT
Practice Address - Zip Code:06051-2637
Practice Address - Country:US
Practice Address - Phone:860-229-2807
Practice Address - Fax:860-229-2812
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000090213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1310450001Medicare NSC
CTT22241Medicare UPIN
CTC02600Medicare ID - Type UnspecifiedGROUP NUMBER