Provider Demographics
NPI:1902004765
Name:SURGICAL ASSOCIATES OF EASTERN CONNECTICUT LLC
Entity Type:Organization
Organization Name:SURGICAL ASSOCIATES OF EASTERN CONNECTICUT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:R
Authorized Official - Middle Name:WINFIELD
Authorized Official - Last Name:RAYNOR
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:860-646-8888
Mailing Address - Street 1:116 E CENTER ST
Mailing Address - Street 2:SUITE 12
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5215
Mailing Address - Country:US
Mailing Address - Phone:860-646-8888
Mailing Address - Fax:860-646-8885
Practice Address - Street 1:116 E CENTER ST
Practice Address - Street 2:SUITE 12
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5215
Practice Address - Country:US
Practice Address - Phone:860-646-8888
Practice Address - Fax:860-646-8885
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-03
Last Update Date:2010-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT26317208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001263177Medicaid
CT001263177Medicaid
CTC03369Medicare PIN