Provider Demographics
NPI:1215105523
Name:OLD AVON ORTHOPEDICS, PC
Entity type:Organization
Organization Name:OLD AVON ORTHOPEDICS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CRYSTAL
Authorized Official - Middle Name:
Authorized Official - Last Name:TRUDEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-678-0022
Mailing Address - Street 1:2 SIMSBURY RD
Mailing Address - Street 2:
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3711
Mailing Address - Country:US
Mailing Address - Phone:860-678-0022
Mailing Address - Fax:860-674-1018
Practice Address - Street 1:2 SIMSBURY RD
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3711
Practice Address - Country:US
Practice Address - Phone:860-678-0022
Practice Address - Fax:860-674-1018
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT18635207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC01271Medicare PIN
B84120Medicare UPIN