1104982826 NPI number — CENTRAL CT SPORTS MEDICINE CENTER

Table of Contents

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:
Provider Other Organization Name Type Code:
6
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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