Basic Information
| Provider Information | |||||||||
| NPI: | 1679950950 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 99 EAST RIVER DR | ||||||||
| Address2: | 5TH FLOOR | ||||||||
| City: | EAST HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 061087301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602824133 | ||||||||
| FaxNumber: | 8602890746 | ||||||||
| Practice Location | |||||||||
| Address1: | 2800 TAMARACK AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | SOUTH WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06074 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606480814 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2015 | ||||||||
| LastUpdateDate: | 05/06/2015 | ||||||||
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| AuthorizedOfficialLastName: | FLANAGAN | ||||||||
| AuthorizedOfficialFirstName: | CHERYL | ||||||||
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| AuthorizedOfficialTitleorPosition: | CREDENTIALER | ||||||||
| AuthorizedOfficialTelephone: | 8602824133 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | 038984 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.