=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285713099
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | USACS OF CONNECTICUT, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/03/2006
-----------------------------------------------------
Last Update Date | 10/16/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 41 BREWSTER RD
-----------------------------------------------------
City | BRISTOL
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06010-5161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
Fax | 330-493-8677
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4535 DRESSLER RD NW
-----------------------------------------------------
City | CANTON
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44718-2545
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
Fax | 330-493-8677
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXEC CHAIR
-----------------------------------------------------
Name | DOMINIC J BAGNOLI JR.
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 330-493-4443
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0204X
-----------------------------------------------------
Taxonomy Name | Pediatric Emergency Medicine (Pediatrics) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------