Basic Information
| Provider Information | |||||||||
| NPI: | 1467986638 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN MANAGEMENT ASSOCIATES OF CONNECTICUT, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 38B GROVE ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068774665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033255700 | ||||||||
| FaxNumber: | 2033258080 | ||||||||
| Practice Location | |||||||||
| Address1: | 38B GROVE ST | ||||||||
| Address2: | |||||||||
| City: | RIDGEFIELD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068774665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033255700 | ||||||||
| FaxNumber: | 2033258080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/14/2017 | ||||||||
| LastUpdateDate: | 04/14/2017 | ||||||||
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| AuthorizedOfficialLastName: | CARLESI | ||||||||
| AuthorizedOfficialFirstName: | VINCENT | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2033255700 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 32179 | CT | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 208VP0014X | 32179 | CT | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pain Medicine | Interventional Pain Medicine |
No ID Information.