Provider Demographics
NPI:1326048984
Name:CONNECTICUT SURGICAL GROUP PC
Entity type:Organization
Organization Name:CONNECTICUT SURGICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF ADMINISTRATIVE OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:MCKELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-524-4326
Mailing Address - Street 1:17 TALCOTT NOTCH RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1818
Mailing Address - Country:US
Mailing Address - Phone:860-524-2626
Mailing Address - Fax:860-677-5029
Practice Address - Street 1:17 TALCOTT NOTCH RD
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06032-1818
Practice Address - Country:US
Practice Address - Phone:860-246-2071
Practice Address - Fax:860-524-2650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
208200000X, 2082S0105X, 2086S0105X, 2086S0122X, 2086S0129X, 2086X0206X, 208800000X, 208C00000X, 208G00000X, 2085R0202X, 2085U0001X, 213E00000X, 213ES0103X, 364SM0705X
CT208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
No2086S0105XAllopathic & Osteopathic PhysiciansSurgerySurgery of the HandGroup - Multi-Specialty
No2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical OncologyGroup - Multi-Specialty
No208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Multi-Specialty
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)Group - Multi-Specialty
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Multi-Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Multi-Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No364SM0705XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistMedical-SurgicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0000S02059OtherCSMS-IPA
CT004201034Medicaid
FL91416185 00Medicaid
CT004139350Medicaid
50CONNSURCT01OtherANTHEM BCBS
MA9781188Medicaid
CT87090OtherAETNA
NY01926310Medicaid
CT004169711OtherDPM# MEDICAID
CTG384943OtherOXFORD
CT87090OtherAETNA
CT1028630001Medicare NSC
CT004169711OtherDPM# MEDICAID
50CONNSURCT01OtherANTHEM BCBS