Provider Demographics
NPI:1730288697
Name:CT COMPREHENSIVE NEUROLOGIC MANAGEMENT, LLC
Entity Type:Organization
Organization Name:CT COMPREHENSIVE NEUROLOGIC MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ROSALIE
Authorized Official - Middle Name:G
Authorized Official - Last Name:MEDNICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-234-1993
Mailing Address - Street 1:2 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NORTH HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06473-2349
Mailing Address - Country:US
Mailing Address - Phone:203-234-1993
Mailing Address - Fax:203-234-7147
Practice Address - Street 1:2 BROADWAY
Practice Address - Street 2:
Practice Address - City:NORTH HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06473-2349
Practice Address - Country:US
Practice Address - Phone:203-234-1993
Practice Address - Fax:203-234-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2010-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0375012084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT0Q3637OtherHEALTHNET
CT3223587OtherAETNA
CTP2491200OtherOXFORD
CT317063OtherWELLCARE
CT9794136003OtherCIGNA
CT010037501CT02OtherANTHEM
CT772945OtherCONNECTICARE
CT3223587OtherAETNA
CT9794136003OtherCIGNA
CT=========OtherMEDSPAN
CT=========OtherPHCS
CT=========OtherHEALTH CT
CT010037501CT02OtherANTHEM
CT3223587OtherAETNA