Provider Demographics
NPI:1619020153
Name:CTR ADV ORTHO & SPORTS MEDICINE PC
Entity Type:Organization
Organization Name:CTR ADV ORTHO & SPORTS MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:PENNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-496-9877
Mailing Address - Street 1:538 LITCHFIELD ST
Mailing Address - Street 2:SUITE G-01
Mailing Address - City:TORRINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06790-6669
Mailing Address - Country:US
Mailing Address - Phone:860-496-9877
Mailing Address - Fax:860-496-0441
Practice Address - Street 1:538 LITCHFIELD ST
Practice Address - Street 2:SUITE G-01
Practice Address - City:TORRINGTON
Practice Address - State:CT
Practice Address - Zip Code:06790-6669
Practice Address - Country:US
Practice Address - Phone:860-496-9877
Practice Address - Fax:860-496-0441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT039414207X00000X
CT493408001332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02991Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER
CT4934080001Medicare NSC