Healthcare Provider Details

I. General information

NPI: 1467082966
Provider Name (Legal Business Name): NEUROSURGERY, ORTHOPAEDICS & SPINE SPECIALISTS, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/23/2020
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 IVY BROOK RD
SHELTON CT
06484-6416
US

IV. Provider business mailing address

2 IVY BROOK RD
SHELTON CT
06484-6416
US

V. Phone/Fax

Practice location:
  • Phone: 203-755-6677
  • Fax: 203-755-7166
Mailing address:
  • Phone: 203-755-6677
  • Fax: 203-755-7166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. WILLIAM GODBURN
Title or Position: CHIEF OPERATING OFFICER
Credential:
Phone: 203-755-6677