MEDICARE: DERMATOLOGY SURGICAL ASSOCIATES, 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	207ND0101X	MOHS-Micrographic Surgery Physician	039399	CT

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	C03194	OTHER	CT	MEDICARE GROUP NUMBER

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9835320	OTHER	CT	CIGNA
2	2V5362	OTHER	CT	HEALTH NET
3	039399	OTHER	CT	CONNECTICARE
4	2000464	OTHER	CT	UNITED HEALTH CARE
6	P2392298	OTHER	CT	OXFORD
7	3672726	OTHER	CT	AETNA
8	010039399CT02	OTHER	CT	ANTHEM BLUE CROSS/BLUE SH

General Provider Information

NPI Number	:	1588859946
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERMATOLOGY SURGICAL ASSOCIATES, LLC

Provider Business Mailing Address
First Line	:	499 FARMINGTON AVE
Second Line	:	SUITE 230
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1933
Country	:	US
Telephone Number	:	860-676-1900
Fax Number	:	860-409-0602

Provider Business Practice Location Address
First Line	:	499 FARMINGTON AVE
Second Line	:	SUITE 230
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1933
Country	:	US
Telephone Number	:	860-676-1900
Fax Number	:	860-409-0602

Authorized Official
Title or Position	:	PHYSICIAN
Name	:	DR. TIMOTHY KYLE CHARTIER
Credential	:
Telephone Number	:	860-676-1900

Provider Enumeration Date	:	09/10/2007
Last Update Date	:	11/23/2011

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