Provider Demographics
NPI:1609441534
Name:SPORTSMED PT OF CONNECTICUT PLLC
Entity Type:Organization
Organization Name:SPORTSMED PT OF CONNECTICUT PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VP OF RCM
Authorized Official - Prefix:
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:
Authorized Official - Last Name:AZAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:201-857-0527
Mailing Address - Street 1:266 HARRISTOWN RD STE 304
Mailing Address - Street 2:
Mailing Address - City:GLEN ROCK
Mailing Address - State:NJ
Mailing Address - Zip Code:07452-3321
Mailing Address - Country:US
Mailing Address - Phone:201-345-5905
Mailing Address - Fax:
Practice Address - Street 1:4775 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06606-1877
Practice Address - Country:US
Practice Address - Phone:201-345-5905
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-24
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty