Healthcare Provider Details

I. General information

NPI: 1952589434
Provider Name (Legal Business Name): CONNECTICUT SURGICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29 HAYNES ST
MANCHESTER CT
06040-4139
US

IV. Provider business mailing address

17 TALCOTT NOTCH RD
FARMINGTON CT
06032-1818
US

V. Phone/Fax

Practice location:
  • Phone: 860-547-0616
  • Fax: 860-524-2655
Mailing address:
  • Phone: 860-547-0616
  • Fax: 860-524-2655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. DOUGLAS C. MCKELL
Title or Position: CAO
Credential:
Phone: 860-524-4326