1104982826 NPI number — CENTRAL CT SPORTS MEDICINE CENTER

Table of content: (NPI 1104982826)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104982826 NPI number — CENTRAL CT SPORTS MEDICINE CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CENTRAL CT SPORTS MEDICINE CENTER
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CENTRAL CT PHYSICAL MEDICINE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104982826
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/05/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 MASSIRIO DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BERLIN
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06037-2322
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-829-1300
Provider Business Mailing Address Fax Number:
860-829-1388

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 MASSIRIO DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BERLIN
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06037-2322
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-829-1300
Provider Business Practice Location Address Fax Number:
860-829-1388
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FELLOWS
Authorized Official First Name:
CATHY
Authorized Official Middle Name:
A.
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
860-829-1300

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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