Provider Demographics
NPI:1184777054
Name:MIDDLETOWN SURGICAL GROUP, PROF CORP
Entity type:Organization
Organization Name:MIDDLETOWN SURGICAL GROUP, PROF CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:A
Authorized Official - Last Name:LONGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-347-2608
Mailing Address - Street 1:520 SAYBROOK ROAD
Mailing Address - Street 2:SUITE S100
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457
Mailing Address - Country:US
Mailing Address - Phone:860-346-2608
Mailing Address - Fax:860-347-4691
Practice Address - Street 1:520 SAYBROOK ROAD
Practice Address - Street 2:SUITE S100
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457
Practice Address - Country:US
Practice Address - Phone:860-346-2608
Practice Address - Fax:860-347-4691
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT45609208600000X, 2086S0129X, 2086X0206X, 208C00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Not Answered2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
Not Answered2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
Not Answered208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
Not Answered208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC00373Medicare ID - Type Unspecified