Basic Information
| Provider Information | |||||||||
| NPI: | 1528535119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, SUITE 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4103291071 | ||||||||
| FaxNumber: | 4103291054 | ||||||||
| Practice Location | |||||||||
| Address1: | 5520 PARK AVE STE WP2-200 | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066113463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037437264 | ||||||||
| FaxNumber: | 2037923920 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2018 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| AuthorizedOfficialLastName: | LEVI | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DOCTOR | ||||||||
| AuthorizedOfficialTelephone: | 2037927246 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332900000X | Y | Suppliers | Non-Pharmacy Dispensing Site |
No ID Information.