Provider Demographics
NPI:1912428160
Name:GM SURGICAL ASSOCIATES LLC
Entity Type:Organization
Organization Name:GM SURGICAL ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:MERIAM
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:917-282-0647
Mailing Address - Street 1:23 MEADOWBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:CT
Mailing Address - Zip Code:06443-2557
Mailing Address - Country:US
Mailing Address - Phone:203-787-6581
Mailing Address - Fax:
Practice Address - Street 1:130 NEW LONDON TPKE STE 3
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2624
Practice Address - Country:US
Practice Address - Phone:860-886-0651
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-28
Last Update Date:2017-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1285869107Medicaid
CT1629218961Medicaid