Provider Demographics
NPI:1992832737
Name:FAIRFIELD COUNTY SURGICAL SPECIALISTS, PC
Entity Type:Organization
Organization Name:FAIRFIELD COUNTY SURGICAL SPECIALISTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RODIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-276-7295
Mailing Address - Street 1:1351 WASHINGTON BLVD
Mailing Address - Street 2:6TH FLOOR
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2419
Mailing Address - Country:US
Mailing Address - Phone:203-276-5959
Mailing Address - Fax:203-276-5969
Practice Address - Street 1:1351 WASHINGTON BLVD
Practice Address - Street 2:6TH FLOOR
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2419
Practice Address - Country:US
Practice Address - Phone:203-276-5959
Practice Address - Fax:203-276-5969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-28
Last Update Date:2007-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004267763Medicaid
CTC03696Medicare PIN