Basic Information
| Provider Information | |||||||||
| NPI: | 1790079382 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE ORTHOPAEDIC & SPORTS MEDICINE CENTER | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE ORTHOPAEDIC & SPORTS MEDICINE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 888 WHITE PLAINS RD | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066114552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032682882 | ||||||||
| FaxNumber: | 2034523097 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 BEARD SAWMILL RD | ||||||||
| Address2: | |||||||||
| City: | SHELTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064846150 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034455550 | ||||||||
| FaxNumber: | 2039251136 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/01/2011 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | POULIN | ||||||||
| AuthorizedOfficialFirstName: | KELLY | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRACTICE ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2032682882 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.