Basic Information
| Provider Information | |||||||||
| NPI: | 1609450568 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PAIN & SPINE SPECIALISTS OF CONNECTICUT, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11350 MCCORMICK RD | ||||||||
| Address2: | EXECUTIVE PLAZA 1, STE. 501 | ||||||||
| City: | HUNT VALLEY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21031 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7039148000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 67 SAND PIT RD STE 308 | ||||||||
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| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068104032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038964319 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/07/2021 | ||||||||
| LastUpdateDate: | 05/07/2021 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RAE | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | M.D. | ||||||||
| AuthorizedOfficialTelephone: | 7039148000 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 05/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247ZC0005X | Y | 193400000X SINGLE SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Pathology | Clinical Laboratory Director, Non-physician |
No ID Information.