1679950950 NPI number — EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC

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 1679950950 NPI number — EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC
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:
1679950950
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/06/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
99 EAST RIVER DR
Provider Second Line Business Mailing Address:
5TH FLOOR
Provider Business Mailing Address City Name:
EAST HARTFORD
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06108-7301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-282-4133
Provider Business Mailing Address Fax Number:
860-289-0746

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2800 TAMARACK AVE
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
SOUTH WINDSOR
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06074
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-648-0814
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/06/2015

Additional Information

Authorized Official

Authorized Official Last Name:
FLANAGAN
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
Authorized Official Title or Position:
CREDENTIALER
Authorized Official Telephone Number:
860-282-4133

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  038984 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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