=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164732426
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORWALK SURGERY CENTER, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2010
-----------------------------------------------------
Last Update Date | 09/16/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 40 CROSS ST STE 120
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-4698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-546-3377
-----------------------------------------------------
Fax | 203-546-3381
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 40 CROSS ST STE 120
-----------------------------------------------------
City | NORWALK
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06851-4698
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 203-546-3377
-----------------------------------------------------
Fax | 203-546-3381
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BOARD MEMBER
-----------------------------------------------------
Name | DR. PAUL PROTOMASTRO
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 914-227-5360
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA1903X
-----------------------------------------------------
Taxonomy Name | Ambulatory Surgical Clinic/Center
-----------------------------------------------------
License Number | PENDING
-----------------------------------------------------
License Number State | CT
-----------------------------------------------------