Provider Demographics
NPI:1306083142
Name:EASTERN CONNECTICUT NEUROSURGERY, P.C.
Entity type:Organization
Organization Name:EASTERN CONNECTICUT NEUROSURGERY, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:R
Authorized Official - Last Name:CRISCUOLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-859-5137
Mailing Address - Street 1:7 MOUNTAINCREST DR
Mailing Address - Street 2:
Mailing Address - City:CHESHIRE
Mailing Address - State:CT
Mailing Address - Zip Code:06410-3554
Mailing Address - Country:US
Mailing Address - Phone:860-859-5137
Mailing Address - Fax:860-859-5177
Practice Address - Street 1:330 WASHINGTON ST
Practice Address - Street 2:SUITE 540
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2700
Practice Address - Country:US
Practice Address - Phone:860-859-5137
Practice Address - Fax:860-859-5177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-15
Last Update Date:2009-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT030418207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001304188Medicaid
CTB69929Medicare UPIN
CT001304188Medicaid