Provider Demographics
NPI:1104982826
Name:CENTRAL CT SPORTS MEDICINE CENTER
Entity type:Organization
Organization Name:CENTRAL CT SPORTS MEDICINE CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:A
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-829-1300
Mailing Address - Street 1:15 MASSIRIO DR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-2322
Mailing Address - Country:US
Mailing Address - Phone:860-829-1300
Mailing Address - Fax:860-829-1388
Practice Address - Street 1:15 MASSIRIO DR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-2322
Practice Address - Country:US
Practice Address - Phone:860-829-1300
Practice Address - Fax:860-829-1388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-28
Last Update Date:2008-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT076573Medicare Oscar/Certification