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General NPI Number Information
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NPI Number | 1679950950
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Entity Type | Organization
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Legal Business Name | EASTERN SPORTS MEDICINE AND SPINE ASSOCIATES LLC
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Dates
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Enumeration Date | 05/06/2015
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Last Update Date | 05/06/2015
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Provider Practice Location Address
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Address Line | 2800 TAMARACK AVE SUITE 104
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City | SOUTH WINDSOR
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State | CT
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Zip | 06074
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Country | US
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Telephone | 860-648-0814
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Fax |
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Provider Business Mailing Address
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Address Line | 99 EAST RIVER DR 5TH FLOOR
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City | EAST HARTFORD
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State | CT
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Zip | 06108-7301
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Country | US
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Telephone | 860-282-4133
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Fax | 860-289-0746
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Authorized Official
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Title or Position | CREDENTIALER
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Name | CHERYL FLANAGAN
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Credential |
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Telephone | 860-282-4133
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207X00000X
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Taxonomy Name | Orthopaedic Surgery Physician
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License Number | 038984
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License Number State | CT
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