Basic Information
Provider Information | |||||||||
NPI: | 1457370447 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ORTHOPEDIC ASSOCIATES SURGERY CENTER LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 505 WILLARD AVE | ||||||||
Address2: | BUILDING 3 | ||||||||
City: | NEWINGTON | ||||||||
State: | CT | ||||||||
PostalCode: | 061112650 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606650174 | ||||||||
FaxNumber: | 8606672066 | ||||||||
Practice Location | |||||||||
Address1: | 1111 CROMWELL AVE | ||||||||
Address2: | BUILDING 1 | ||||||||
City: | ROCKY HILL | ||||||||
State: | CT | ||||||||
PostalCode: | 060673449 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8605290295 | ||||||||
FaxNumber: | 8605292390 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/19/2006 | ||||||||
LastUpdateDate: | 02/14/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MINEAU | ||||||||
AuthorizedOfficialFirstName: | KRIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 8606650174 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
ID Information
ID | Type | State | Issuer | Description | 004246874 | 05 | CT |   | MEDICAID |