Basic Information
Provider Information | |||||||||
NPI: | 1174826598 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 67 SAND PIT RD SUITE 308 | ||||||||
Address2: |   | ||||||||
City: | DANBURY | ||||||||
State: | CT | ||||||||
PostalCode: | 068104032 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2037437246 | ||||||||
FaxNumber: | 2037923920 | ||||||||
Practice Location | |||||||||
Address1: | 131 KENT RD BLDG A | ||||||||
Address2: |   | ||||||||
City: | NEW MILFORD | ||||||||
State: | CT | ||||||||
PostalCode: | 067763485 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8602108161 | ||||||||
FaxNumber: | 8602108175 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2010 | ||||||||
LastUpdateDate: | 11/09/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LEVI | ||||||||
AuthorizedOfficialFirstName: | DAVID | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 2037437246 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 038785 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |   |
No ID Information.