Provider Demographics
NPI:1174801898
Name:MIDDLESEX PLASTIC SURGERY CENTER,LLC
Entity type:Organization
Organization Name:MIDDLESEX PLASTIC SURGERY CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARI
Authorized Official - Middle Name:
Authorized Official - Last Name:REBANE-MAZZOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-343-0122
Mailing Address - Street 1:535 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4743
Mailing Address - Country:US
Mailing Address - Phone:860-343-0122
Mailing Address - Fax:860-347-2212
Practice Address - Street 1:535 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4743
Practice Address - Country:US
Practice Address - Phone:860-343-0122
Practice Address - Fax:860-347-2212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049437208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT049437OtherOWNER OPERATOR LIC #