Provider Demographics
NPI:1053395400
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:860-547-0616
Mailing Address - Fax:860-524-2655
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:STE 409
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-547-0616
Practice Address - Fax:860-524-2655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2010-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01926310Medicaid
MA9781188Medicaid
CT004169711Medicaid
CT50CONNSURCT01OtherANTHEM BCBS
CT004201034Medicaid
CT87090OtherAETNA
CT0000S02059OtherHEALTH NET VENDOR #
CT50CONNSURCT01OtherANTHEM BCBS
NY01926310Medicaid
CTC02779Medicare PIN