Provider Demographics
NPI:1003224569
Name:EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC
Entity Type:Organization
Organization Name:EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALER
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:FLANAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-282-4133
Mailing Address - Street 1:99 E RIVER DR
Mailing Address - Street 2:5TH FLOOR
Mailing Address - City:EAST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06108-3288
Mailing Address - Country:US
Mailing Address - Phone:860-282-4133
Mailing Address - Fax:
Practice Address - Street 1:701 COTTAGE GROVE ROAD
Practice Address - Street 2:E230
Practice Address - City:BLOOMFIELD
Practice Address - State:CT
Practice Address - Zip Code:06002
Practice Address - Country:US
Practice Address - Phone:860-648-0814
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-29
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty