Provider Demographics
NPI:1477197671
Name:SPINE CENTER OF CT, PLLC
Entity Type:Organization
Organization Name:SPINE CENTER OF CT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RAE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:571-223-8770
Mailing Address - Street 1:11350 MCCORMICK RD
Mailing Address - Street 2:EXECUTIVE PLAZA 1, SUITE 501
Mailing Address - City:HUNT VALLEY
Mailing Address - State:MD
Mailing Address - Zip Code:21031-1002
Mailing Address - Country:US
Mailing Address - Phone:410-329-1071
Mailing Address - Fax:410-329-1054
Practice Address - Street 1:67 SAND PIT RD STE 308
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-4032
Practice Address - Country:US
Practice Address - Phone:203-743-7264
Practice Address - Fax:203-792-3920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-30
Last Update Date:2019-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Single Specialty