Provider Demographics
NPI: | 1518940204 |
---|---|
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: | 17 TALCOTT NOTCH RD |
Mailing Address - Street 2: | |
Mailing Address - City: | FARMINGTON |
Mailing Address - State: | CT |
Mailing Address - Zip Code: | 06032-1818 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 860-246-2071 |
Mailing Address - Fax: | 860-524-2650 |
Practice Address - Street 1: | 120 SIMSBURY RD |
Practice Address - Street 2: | |
Practice Address - City: | AVON |
Practice Address - State: | CT |
Practice Address - Zip Code: | 06001-3735 |
Practice Address - Country: | US |
Practice Address - Phone: | 860-246-2071 |
Practice Address - Fax: | 860-678-8262 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2005-11-28 |
Last Update Date: | 2010-08-11 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 332B00000X | Suppliers | Durable Medical Equipment & Medical Supplies | ||
No | 208200000X | Allopathic & Osteopathic Physicians | Plastic Surgery | Group - Multi-Specialty | |
No | 2082S0105X | Allopathic & Osteopathic Physicians | Plastic Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 2085R0202X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | Group - Multi-Specialty |
No | 2085U0001X | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Ultrasound | Group - Multi-Specialty |
No | 208600000X | Allopathic & Osteopathic Physicians | Surgery | Group - Multi-Specialty | |
No | 2086S0105X | Allopathic & Osteopathic Physicians | Surgery | Surgery of the Hand | Group - Multi-Specialty |
No | 2086S0122X | Allopathic & Osteopathic Physicians | Surgery | Plastic and Reconstructive Surgery | Group - Multi-Specialty |
No | 2086S0129X | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | Group - Multi-Specialty |
No | 2086X0206X | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | Group - Multi-Specialty |
No | 208800000X | Allopathic & Osteopathic Physicians | Urology | Group - Multi-Specialty | |
No | 208C00000X | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | Group - Multi-Specialty | |
No | 208G00000X | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) | Group - Multi-Specialty | |
No | 213E00000X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Group - Multi-Specialty | |
No | 213ES0103X | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery | Group - Multi-Specialty |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
CT | 0000S03059 | Other | HEALTH NET |
CT | 004201034 | Medicaid | |
CT | 004169711 | Medicaid | |
MA | 9781188 | Medicaid | |
NY | 01926310 | Medicaid | |
CT | 87090 | Other | AETNA |
CT | 50CONNSURCT01 | Other | ANTHEM BCBS |
CT | 004139350 | Medicaid | |
MA | 9781188 | Medicaid | |
MA | 9781188 | Medicaid | |
CT | 1028630002 | Medicare NSC | |
CT | 004139350 | Medicaid |