Basic Information
| Provider Information | |||||||||
| NPI: | 1558474742 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MIDDLESEX ORTHOPEDIC SURGEONS PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606858940 | ||||||||
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| Practice Location | |||||||||
| Address1: | 410 SAYBROOK RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606858940 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2006 | ||||||||
| LastUpdateDate: | 05/11/2012 | ||||||||
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| AuthorizedOfficialLastName: | O'DONNELL | ||||||||
| AuthorizedOfficialFirstName: | SEAN | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | OFFICER/SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 8606858940 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 174400000X | CT | N | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist | 207X00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 004000469 | 05 | CT | MEDICAID |