Provider Demographics
NPI:1932234440
Name:ORTHOPAEDIC & SPORTS MEDICINE CTR PC
Entity Type:Organization
Organization Name:ORTHOPAEDIC & SPORTS MEDICINE CTR PC
Other - Org Name:THE ORTHOPAEDIC & SPORTS MEDICINE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:POULIN
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:203-268-2882
Mailing Address - Street 1:888 WHITE PLAINS RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-4552
Mailing Address - Country:US
Mailing Address - Phone:203-268-2882
Mailing Address - Fax:203-452-3097
Practice Address - Street 1:888 WHITE PLAINS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-4552
Practice Address - Country:US
Practice Address - Phone:203-268-2882
Practice Address - Fax:203-452-3097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01546Medicare ID - Type UnspecifiedMEDICARE
CT0901120001Medicare NSC