Basic Information
| Provider Information | |||||||||
| NPI: | 1902004765 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SURGICAL ASSOCIATES OF EASTERN CONNECTICUT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 116 E CENTER ST | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060405215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606468888 | ||||||||
| FaxNumber: | 8606468885 | ||||||||
| Practice Location | |||||||||
| Address1: | 116 E CENTER ST | ||||||||
| Address2: | SUITE 12 | ||||||||
| City: | MANCHESTER | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060405215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606468888 | ||||||||
| FaxNumber: | 8606468885 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2007 | ||||||||
| LastUpdateDate: | 08/20/2010 | ||||||||
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| AuthorizedOfficialLastName: | RAYNOR | ||||||||
| AuthorizedOfficialFirstName: | R | ||||||||
| AuthorizedOfficialMiddleName: | WINFIELD | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8606468888 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 26317 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001263177 | 05 | CT | MEDICAID |