Basic Information
| Provider Information | |||||||||
| NPI: | 1669653283 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRAL CONNECTICUT NEUROSURGERY AND SPINE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 LIBERTY SQ FL 1 | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060512637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602251227 | ||||||||
| FaxNumber: | 8602251253 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 LIBERTY SQ FL 1 | ||||||||
| Address2: | |||||||||
| City: | NEW BRITAIN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060512637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602251227 | ||||||||
| FaxNumber: | 8602251253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/26/2007 | ||||||||
| LastUpdateDate: | 05/29/2019 | ||||||||
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| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | AHMED | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER / PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 8602251227 | ||||||||
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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 | 207T00000X | 039336 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | CO3839 | 01 | CT | MEDICARE PTAN | OTHER |