Provider Demographics
NPI:1851920029
Name:PRISM SPORTS MEDICINE, LLC
Entity Type:Organization
Organization Name:PRISM SPORTS MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CARL
Authorized Official - Middle Name:
Authorized Official - Last Name:NISSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-282-4128
Mailing Address - Street 1:35 MOUNTAIN SPRING RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06032-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:31 SEYMOUR STREET
Practice Address - Street 2:SUITE 204
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106
Practice Address - Country:US
Practice Address - Phone:860-282-0833
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-08
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT00000000Medicaid