MEDICARE: SPINE & SPORTS CENTER OF CONNECTICUT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208100000X	Physical Medicine & Rehabilitation Physician

General Provider Information

NPI Number	:	1225096704
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SPINE & SPORTS CENTER OF CONNECTICUT

Provider Business Mailing Address
First Line	:	500 CHASE PKWY
Second Line	:	500 CHASE PARKWAY
City	:	WATERBURY
State	:	CT
Zip	:	06708-3346
Country	:	US
Telephone Number	:	203-573-1167
Fax Number	:	203-573-1272

Provider Business Practice Location Address
First Line	:	500 CHASE PKWY
Second Line	:	500 CHASE PARKWAY
City	:	WATERBURY
State	:	CT
Zip	:	06708-3346
Country	:	US
Telephone Number	:	203-573-1167
Fax Number	:	203-573-1272

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	DAVID C. NESS
Credential	:
Telephone Number	:	203-573-1423

Provider Enumeration Date	:	05/03/2006
Last Update Date	:	08/22/2020

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