Provider Demographics
NPI:1588983415
Name:INTERVENTIONAL SPINE & SPORTS MEDICINE, PC
Entity type:Organization
Organization Name:INTERVENTIONAL SPINE & SPORTS MEDICINE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BHAVESH
Authorized Official - Middle Name:R
Authorized Official - Last Name:PATEL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-645-8859
Mailing Address - Street 1:1579 STRAITS TPKE
Mailing Address - Street 2:TURNPIKE OFFICE PARK
Mailing Address - City:MIDDLEBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06762-1835
Mailing Address - Country:US
Mailing Address - Phone:203-598-7246
Mailing Address - Fax:203-598-0200
Practice Address - Street 1:1579 STRAITS TPKE
Practice Address - Street 2:TURNPIKE OFFICE PARK
Practice Address - City:MIDDLEBURY
Practice Address - State:CT
Practice Address - Zip Code:06762-1835
Practice Address - Country:US
Practice Address - Phone:203-598-7246
Practice Address - Fax:203-598-0200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-05-17
Last Update Date:2024-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040593208VP0000X, 208100000X
363L00000X, 363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400023980Medicare UPIN