Basic Information
| Provider Information | |||||||||
| NPI: | 1225096704 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SPINE & SPORTS CENTER OF CONNECTICUT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 500 CHASE PKWY | ||||||||
| Address2: | 500 CHASE PARKWAY | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035731167 | ||||||||
| FaxNumber: | 2035731272 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 CHASE PKWY | ||||||||
| Address2: | 500 CHASE PARKWAY | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067083346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035731167 | ||||||||
| FaxNumber: | 2035731272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | NESS | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2035731423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.