Basic Information
| Provider Information | |||||||||
| NPI: | 1851920029 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRISM SPORTS MEDICINE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 35 MOUNTAIN SPRING RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060321612 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 31 SEYMOUR STREET | ||||||||
| Address2: | SUITE 204 | ||||||||
| City: | HARTFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 06106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602820833 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2020 | ||||||||
| LastUpdateDate: | 04/08/2020 | ||||||||
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| AuthorizedOfficialLastName: | NISSEN | ||||||||
| AuthorizedOfficialFirstName: | CARL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8602824128 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/08/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207X00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00000000 | 05 | CT | MEDICAID |