MEDICARE: NORTHWEST PHYSICAL MEDICINE. 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	208100000X	Physical Medicine & Rehabilitation Physician	040327	CT

General Provider Information

NPI Number	:	1710052725
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	NORTHWEST PHYSICAL MEDICINE. LLC

Provider Business Mailing Address
First Line	:	1185 NEW LITCHFIELD ST
Second Line	:
City	:	TORRINGTON
State	:	CT
Zip	:	06790-6017
Country	:	US
Telephone Number	:	860-496-0333
Fax Number	:	860-496-0333

Provider Business Practice Location Address
First Line	:	1185 NEW LITCHFIELD ST
Second Line	:
City	:	TORRINGTON
State	:	CT
Zip	:	06790-6017
Country	:	US
Telephone Number	:	860-496-0333
Fax Number	:	860-496-0948

Authorized Official
Title or Position	:	OWNER
Name	:	JOHN R CARBON
Credential	:	DO
Telephone Number	:	860-496-0333

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	11/08/2010

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