1558476069 NPI number — NEUROSURGEONS OF CENTRAL CONNECTICUT, PC

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 1558476069 NPI number — NEUROSURGEONS OF CENTRAL CONNECTICUT, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEUROSURGEONS OF CENTRAL CONNECTICUT, PC
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:
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:
1558476069
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 RETREAT AVE
Provider Second Line Business Mailing Address:
#705
Provider Business Mailing Address City Name:
HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06106-2528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-278-0070
Provider Business Mailing Address Fax Number:
860-522-6081

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 RETREAT AVE
Provider Second Line Business Practice Location Address:
#705
Provider Business Practice Location Address City Name:
HARTFORD
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06106-2528
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-278-0070
Provider Business Practice Location Address Fax Number:
860-522-6081
Provider Enumeration Date:
08/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KVAM
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT, NSCC
Authorized Official Telephone Number:
860-282-4137

Provider Taxonomy Codes

  • Taxonomy code: 207T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 004116233 , issued by the state of ( CT ) . This identifiers is of the category "MEDICAID".




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