Basic Information
| Provider Information | |||||||||
| NPI: | 1457619660 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN & SPINE SPECIALISTS OF CONNECTICUT LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 67 SAND PIT RD | ||||||||
| Address2: | 308 | ||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037437246 | ||||||||
| FaxNumber: | 2037923920 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 PARK AVE | ||||||||
| Address2: | 303 | ||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066113463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033737330 | ||||||||
| FaxNumber: | 2033737354 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2012 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| AuthorizedOfficialLastName: | LEVI | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2037437246 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 6472130003 | 01 | CT | PTAN | OTHER |