Basic Information
| Provider Information | |||||||||
| NPI: | 1558476069 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NEUROSURGEONS OF CENTRAL CONNECTICUT, PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | #705 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602780070 | ||||||||
| FaxNumber: | 8605226081 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 RETREAT AVE | ||||||||
| Address2: | #705 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061062528 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602780070 | ||||||||
| FaxNumber: | 8605226081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2006 | ||||||||
| LastUpdateDate: | 12/18/2013 | ||||||||
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| AuthorizedOfficialLastName: | KVAM | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT, NSCC | ||||||||
| AuthorizedOfficialTelephone: | 8602824137 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 004116233 | 05 | CT | MEDICAID |