Basic Information
| Provider Information | |||||||||
| NPI: | 1861614588 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CONNECTICUT ORTHOPAEDIC SPECIALISTS, PC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STAR SPORTS THERAPY AND REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2408 WHITNEY AVE | ||||||||
| Address2: | |||||||||
| City: | HAMDEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065183209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2034073500 | ||||||||
| FaxNumber: | 2032811164 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 YALE AVE | ||||||||
| Address2: | |||||||||
| City: | WALLINGFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064921838 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2032940449 | ||||||||
| FaxNumber: | 2032848271 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 02/17/2016 | ||||||||
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| AuthorizedOfficialLastName: | ELIA | ||||||||
| AuthorizedOfficialFirstName: | GLENN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2034073576 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CONNECTICUT ORTHOPAEDIC SPECIALISTS, PC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | N | Suppliers | Durable Medical Equipment & Medical Supplies | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 225100000X | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004255247 | 05 | CT | MEDICAID |