Basic Information
| Provider Information | |||||||||
| NPI: | 1184777054 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLETOWN SURGICAL GROUP, PROF CORP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 SAYBROOK ROAD | ||||||||
| Address2: | SUITE S100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
| FaxNumber: | 8603474691 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 SAYBROOK ROAD | ||||||||
| Address2: | SUITE S100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
| FaxNumber: | 8603474691 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | LONGO | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | A. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8603472608 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 45609 | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | 2086S0129X | 45609 | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086X0206X | 45609 | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | 45609 | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208G00000X | 45609 | CT | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
No ID Information.