Healthcare Provider Details

I. General information

NPI: 1932234440
Provider Name (Legal Business Name): ORTHOPAEDIC & SPORTS MEDICINE CTR PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

888 WHITE PLAINS RD SUITE 105
TRUMBULL CT
06611-4552
US

IV. Provider business mailing address

888 WHITE PLAINS RD SUITE 105
TRUMBULL CT
06611-4552
US

V. Phone/Fax

Practice location:
  • Phone: 203-268-2882
  • Fax: 203-452-3097
Mailing address:
  • Phone: 203-268-2882
  • Fax: 203-452-3097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MISS KELLY M POULIN I
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 203-268-2882