Provider Demographics
NPI:1356411284
Name:SURGICAL SPECIALTIES OF EASTERN CT LLC
Entity type:Organization
Organization Name:SURGICAL SPECIALTIES OF EASTERN CT LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:MR
Authorized Official - First Name:HARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:ANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-646-2457
Mailing Address - Street 1:116 E CENTER ST STE 14
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-5215
Mailing Address - Country:US
Mailing Address - Phone:860-646-8457
Mailing Address - Fax:860-646-6388
Practice Address - Street 1:116 E CENTER ST
Practice Address - Street 2:SUITE 14
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-5215
Practice Address - Country:US
Practice Address - Phone:860-646-8457
Practice Address - Fax:860-646-6388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT043351208600000X
CT020769208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC59711Medicare UPIN
CTH97987Medicare UPIN