Provider Demographics
NPI:1871634279
Name:CONNECTICUT CENTER FOR ORTHOPEDIC SURGERY, LLC
Entity Type:Organization
Organization Name:CONNECTICUT CENTER FOR ORTHOPEDIC SURGERY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:T
Authorized Official - Last Name:MAZZARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-649-0047
Mailing Address - Street 1:29 HAYNES ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-4139
Mailing Address - Country:US
Mailing Address - Phone:860-649-0047
Mailing Address - Fax:860-288-2107
Practice Address - Street 1:29 HAYNES ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-4139
Practice Address - Country:US
Practice Address - Phone:860-649-0047
Practice Address - Fax:860-288-2107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03717Medicare PIN
CT6048230001Medicare NSC