Basic Information
| Provider Information | |||||||||
| NPI: | 1902000276 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CONNECTICUT NEUROSURGICAL SPECIALISTS, P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 267 GRANT STREET | ||||||||
| Address2: | SCHINE 8 | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033844500 | ||||||||
| FaxNumber: | 2033843812 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT STREET | ||||||||
| Address2: | SCHINE 8 | ||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033844500 | ||||||||
| FaxNumber: | 2033843812 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2007 | ||||||||
| LastUpdateDate: | 03/01/2013 | ||||||||
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| AuthorizedOfficialLastName: | LIPOW | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | IRWIN | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2033844500 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 026386 | CT | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001359018 | 05 | CT | MEDICAID | 001263862 | 05 | CT | MEDICAID |