Provider Demographics
NPI:1669492583
Name:CROSSROADS ORTHOPAEDIC SUBSPECIALISTS LLC
Entity Type:Organization
Organization Name:CROSSROADS ORTHOPAEDIC SUBSPECIALISTS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATER
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:STAHELSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-442-5361
Mailing Address - Street 1:196 PARKWAY S STE 201
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06385-1234
Mailing Address - Country:US
Mailing Address - Phone:860-442-5361
Mailing Address - Fax:860-437-0318
Practice Address - Street 1:196 PARKWAY S STE 201
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:CT
Practice Address - Zip Code:06385-1234
Practice Address - Country:US
Practice Address - Phone:860-442-5361
Practice Address - Fax:860-437-0318
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT5881960001Medicare NSC
CTC03419Medicare PIN