MEDICARE: PLASTIC AND RECONSTRUCTIVE SURGERY SPECIALISTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2086S0122X	Plastic and Reconstructive Surgery Physician	040166	CT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538249842
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PLASTIC AND RECONSTRUCTIVE SURGERY SPECIALISTS LLC

Provider Business Mailing Address
First Line	:	2 IVY BROOK RD
Second Line	:	SUITE 105
City	:	SHELTON
State	:	CT
Zip	:	06484-6416
Country	:	US
Telephone Number	:	203-924-2900
Fax Number	:	203-924-1300

Provider Business Practice Location Address
First Line	:	2 IVY BROOK RD
Second Line	:	SUITE 105
City	:	SHELTON
State	:	CT
Zip	:	06484-6416
Country	:	US
Telephone Number	:	203-924-2900
Fax Number	:	203-924-1300

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN F REILLY
Credential	:	MD
Telephone Number	:	203-924-2900

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	03/16/2015

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