MEDICARE: COMPREHENSIVE OCCUPATIONAL MED ASOC OF CONNECTICUT,PC

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	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1760625917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMPREHENSIVE OCCUPATIONAL MED ASOC OF CONNECTICUT,PC

Provider Business Mailing Address
First Line	:	12000 SUNRISE VALLEY DR BLDG E
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-3403
Country	:	US
Telephone Number	:	703-592-7111
Fax Number	:

Provider Business Practice Location Address
First Line	:	12000 SUNRISE VALLEY DR BLDG E
Second Line	:
City	:	RESTON
State	:	VA
Zip	:	20191-3403
Country	:	US
Telephone Number	:	615-468-6548
Fax Number	:	615-468-0477

Authorized Official
Title or Position	:	CREDENTIALING SPRCIALIST
Name	:	TINA R SPICER
Credential	:
Telephone Number	:	615-468-6548

Provider Enumeration Date	:	04/16/2009
Last Update Date	:	05/08/2009

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