Healthcare Provider Details

I. General information

NPI: 1851920029
Provider Name (Legal Business Name): PRISM SPORTS MEDICINE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2020
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 SEYMOUR ST STE 204
HARTFORD CT
06106-5505
US

IV. Provider business mailing address

31 PINNACLE RIDGE RD
FARMINGTON CT
06032-3041
US

V. Phone/Fax

Practice location:
  • Phone: 860-421-3233
  • Fax:
Mailing address:
  • Phone: 860-421-3233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number
License Number State

VIII. Authorized Official

Name: CARL NISSEN
Title or Position: OWNER
Credential: MD
Phone: 860-282-4128