Basic Information
Provider Information | |||||||||
NPI: | 1003224569 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
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Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
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OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
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OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 99 E RIVER DR | ||||||||
Address2: | 5TH FLOOR | ||||||||
City: | EAST HARTFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 061083288 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602824133 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 701 COTTAGE GROVE ROAD | ||||||||
Address2: | E230 | ||||||||
City: | BLOOMFIELD | ||||||||
State: | CT | ||||||||
PostalCode: | 06002 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8606480814 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2014 | ||||||||
LastUpdateDate: | 05/04/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | FLANAGAN | ||||||||
AuthorizedOfficialFirstName: | CHERYL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CREDENTIALER | ||||||||
AuthorizedOfficialTelephone: | 8602824133 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
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NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X |   |   | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |   |
No ID Information.