Provider Demographics
NPI:1114979614
Name:SEACOAST ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC
Entity Type:Organization
Organization Name:SEACOAST ORTHOPEDIC SURGERY & SPORTS MEDICINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:B
Authorized Official - Last Name:CARLOW
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-449-1413
Mailing Address - Street 1:495 ROUTE 184
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340
Mailing Address - Country:US
Mailing Address - Phone:860-449-1413
Mailing Address - Fax:860-449-0390
Practice Address - Street 1:495 ROUTE 184
Practice Address - Street 2:SUITE 300
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340
Practice Address - Country:US
Practice Address - Phone:860-449-1413
Practice Address - Fax:860-449-0390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-16
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT047870OtherLICENSE NUMBER
CT001409756Medicaid
CT001272939Medicaid
CT040975OtherLICENSE NUMBER
CT001253582Medicaid
CT004237146Medicaid
CT001272939Medicaid
CT001253582Medicaid
D02606Medicare UPIN