MEDICARE: CONNECTICUT SURGICAL GROUP, PC

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	335E00000X	Prosthetic/Orthotic Supplier
2	332B00000X	Durable Medical Equipment & Medical Supplies

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
2	50CONNSURCT01	OTHER	CT	ANTHEM BCBS

General Provider Information

NPI Number	:	1972586675
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTICUT SURGICAL GROUP, PC

Provider Business Mailing Address
First Line	:	17 TALCOTT NOTCH RD
Second Line	:
City	:	FARMINGTON
State	:	CT
Zip	:	06032-1818
Country	:	US
Telephone Number	:	860-524-2626
Fax Number	:	860-677-5029

Provider Business Practice Location Address
First Line	:	98 MAIN ST
Second Line	:	SUITE 303
City	:	SOUTHINGTON
State	:	CT
Zip	:	06489-2500
Country	:	US
Telephone Number	:	203-238-1241
Fax Number	:	860-686-0791

Authorized Official
Title or Position	:	CHIEF ADMINISTRATIVE OFFICER
Name	:	DOUGLAS C MCKELL
Credential	:
Telephone Number	:	860-524-4326

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	10/21/2010

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