Basic Information
| Provider Information | |||||||||
| NPI: | 1467057372 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SOUTHWEST CONNECTICUT SURGERY CENTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1434 | ||||||||
| Address2: | |||||||||
| City: | AVON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060011434 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606673542 | ||||||||
| FaxNumber: | 8606672066 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 DANBURY RD | ||||||||
| Address2: | |||||||||
| City: | WILTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068974406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4762576500 | ||||||||
| FaxNumber: | 4752576520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2020 | ||||||||
| LastUpdateDate: | 06/15/2021 | ||||||||
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| AuthorizedOfficialLastName: | FORMEISTER | ||||||||
| AuthorizedOfficialFirstName: | LUCILLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR BUSINESS SYSTEMS | ||||||||
| AuthorizedOfficialTelephone: | 8606679542 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 06/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QA1903X | Y | Ambulatory Health Care Facilities | Clinic/Center | Ambulatory Surgical |
No ID Information.