Provider Demographics
NPI:1871794008
Name:CONNECTICUT NEUROSURGERY & SPINE ASSOC., LLC
Entity type:Organization
Organization Name:CONNECTICUT NEUROSURGERY & SPINE ASSOC., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREW
Authorized Official - Middle Name:ERVIN
Authorized Official - Last Name:WAKEFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-246-1636
Mailing Address - Street 1:85 SEYMOUR ST
Mailing Address - Street 2:SUITE 707
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5501
Mailing Address - Country:US
Mailing Address - Phone:860-246-1636
Mailing Address - Fax:860-522-3119
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 707
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-246-1636
Practice Address - Fax:860-522-3119
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037617207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC03173Medicare ID - Type Unspecified