Provider Demographics
NPI:1023113701
Name:SURGICAL CENTER OF CONNECTICUT LLC
Entity type:Organization
Organization Name:SURGICAL CENTER OF CONNECTICUT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:A
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-371-2986
Mailing Address - Street 1:4920 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-1300
Mailing Address - Country:US
Mailing Address - Phone:203-371-2986
Mailing Address - Fax:203-371-2987
Practice Address - Street 1:4920 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1300
Practice Address - Country:US
Practice Address - Phone:203-371-2986
Practice Address - Fax:203-371-2987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004248862Medicaid
CT004248862Medicaid
CT004248862Medicaid