Healthcare Provider Details

I. General information

NPI: 1376742031
Provider Name (Legal Business Name): CONNECTICUT SPINE AND DISC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2007
Last Update Date: 06/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1579 STRAITS TPKE
MIDDLEBURY CT
06762-1835
US

IV. Provider business mailing address

1579 STRAITS TPKE
MIDDLEBURY CT
06762-1835
US

V. Phone/Fax

Practice location:
  • Phone: 203-758-2003
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number041372
License Number StateCT

VIII. Authorized Official

Name: DR. CHARLES E RAFTERY
Title or Position: OWNER
Credential: MD
Phone: 203-758-2003