Healthcare Provider Details

I. General information

NPI: 1023291622
Provider Name (Legal Business Name): CONNECTICUT SURGICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 LEWIS AVE SUITE 210
MERIDEN CT
06451-2121
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 Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

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