Provider Demographics
NPI:1255660817
Name:FAIRFIELD SPORTS AND SPINE LLC
Entity Type:Organization
Organization Name:FAIRFIELD SPORTS AND SPINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:R
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:MD MS
Authorized Official - Phone:203-372-0649
Mailing Address - Street 1:10 WIMBLEDON LN
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:CT
Mailing Address - Zip Code:06612-1238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:650 CLINTON AVE
Practice Address - Street 2:SECOND FLOOR
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06605-1704
Practice Address - Country:US
Practice Address - Phone:203-372-0649
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-10
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports MedicineGroup - Single Specialty