Healthcare Provider Details

I. General information

NPI: 1922170786
Provider Name (Legal Business Name): CONNECTICUT SURGICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 03/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

680 SOUTH MAIN STREET LOWER LEVEL 2
CHESHIRE CT
06410-3190
US

IV. Provider business mailing address

17 TALCOTT NOTCH RD
FARMINGTON CT
06032-1818
US

V. Phone/Fax

Practice location:
  • Phone: 203-238-1241
  • Fax: 203-686-0791
Mailing address:
  • Phone: 860-524-2626
  • Fax: 860-677-5029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State

VIII. Authorized Official

Name: DOUGLAS C. MCKELL
Title or Position: CHIEF ADMINISTRATIVE OFFICER
Credential:
Phone: 860-524-4326