Provider Demographics
NPI:1265402416
Name:COLON ANDRECTAL SURGEONS OF FAIRFIELD COUNTY, LLC
Entity type:Organization
Organization Name:COLON ANDRECTAL SURGEONS OF FAIRFIELD COUNTY, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:PICCIOLI
Authorized Official - Suffix:
Authorized Official - Credentials:BA
Authorized Official - Phone:203-331-8700
Mailing Address - Street 1:2660 MAIN ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06606-5369
Mailing Address - Country:US
Mailing Address - Phone:203-331-8700
Mailing Address - Fax:203-335-5819
Practice Address - Street 1:2660 MAIN ST
Practice Address - Street 2:SUITE 302
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-5369
Practice Address - Country:US
Practice Address - Phone:203-331-8700
Practice Address - Fax:203-335-5819
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01799Medicare ID - Type UnspecifiedGROUP #