Provider Demographics
NPI:1154363653
Name:CONNECTICUT SPINE AND SPORTS PHYSICIANS, INC.
Entity type:Organization
Organization Name:CONNECTICUT SPINE AND SPORTS PHYSICIANS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:R
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-284-1872
Mailing Address - Street 1:50 S MAIN ST
Mailing Address - Street 2:SUITE 2E
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-4219
Mailing Address - Country:US
Mailing Address - Phone:203-284-1872
Mailing Address - Fax:203-284-1874
Practice Address - Street 1:50 S MAIN ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-4219
Practice Address - Country:US
Practice Address - Phone:203-284-1872
Practice Address - Fax:203-284-1874
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03438Medicare ID - Type Unspecified