Provider Demographics
NPI:1972586675
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:
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 1:98 MAIN ST
Practice Address - Street 2:SUITE 303
Practice Address - City:SOUTHINGTON
Practice Address - State:CT
Practice Address - Zip Code:06489-2500
Practice Address - Country:US
Practice Address - Phone:203-238-1241
Practice Address - Fax:860-686-0791
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-28
Last Update Date:2010-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004139350Medicaid
CT50CONNSURCT01OtherANTHEM BCBS
CT1028630003Medicare NSC
CT50CONNSURCT01OtherANTHEM BCBS
CTC20779Medicare PIN