Provider Demographics
NPI:1558476069
Name:NEUROSURGEONS OF CENTRAL CONNECTICUT, PC
Entity Type:Organization
Organization Name:NEUROSURGEONS OF CENTRAL CONNECTICUT, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, NSCC
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:KVAM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-282-4137
Mailing Address - Street 1:100 RETREAT AVE
Mailing Address - Street 2:#705
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-2528
Mailing Address - Country:US
Mailing Address - Phone:860-278-0070
Mailing Address - Fax:860-522-6081
Practice Address - Street 1:100 RETREAT AVE
Practice Address - Street 2:#705
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-2528
Practice Address - Country:US
Practice Address - Phone:860-278-0070
Practice Address - Fax:860-522-6081
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-21
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004116233Medicaid
CTC01354Medicare ID - Type Unspecified