MEDICARE: CONNECTICUT SPINE INSTITUTE LLC

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	174400000X	Specialist

General Provider Information

NPI Number	:	1407086762
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CONNECTICUT SPINE INSTITUTE LLC

Provider Business Mailing Address
First Line	:	25 VALLEY DR
Second Line	:
City	:	GREENWICH
State	:	CT
Zip	:	06831-5203
Country	:	US
Telephone Number	:	203-661-3333
Fax Number	:	203-661-5610

Provider Business Practice Location Address
First Line	:	25 VALLEY DR
Second Line	:
City	:	GREENWICH
State	:	CT
Zip	:	06831-5203
Country	:	US
Telephone Number	:	203-661-3333
Fax Number	:	203-661-5610

Authorized Official
Title or Position	:	OFFICE ADMINISTRATOR
Name	:	MICHELLE MCDERMOTT
Credential	:
Telephone Number	:	203-661-3333

Provider Enumeration Date	:	07/21/2009
Last Update Date	:	07/31/2009

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Directions to “CONNECTICUT SPINE INSTITUTE LLC ” Practice Location

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