Provider Demographics
NPI:1871799635
Name:VALLEY SPORTS PHYSICIANS & ORTHOPEDIC MEDICINE
Entity type:Organization
Organization Name:VALLEY SPORTS PHYSICIANS & ORTHOPEDIC MEDICINE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE / BILLING MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WEDDERBURN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:860-675-0357
Mailing Address - Street 1:54 W AVON RD
Mailing Address - Street 2:SUITE 202
Mailing Address - City:AVON
Mailing Address - State:CT
Mailing Address - Zip Code:06001-3680
Mailing Address - Country:US
Mailing Address - Phone:860-675-0357
Mailing Address - Fax:860-675-0358
Practice Address - Street 1:54 W AVON RD
Practice Address - Street 2:SUITE 202
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-3680
Practice Address - Country:US
Practice Address - Phone:860-675-0357
Practice Address - Fax:860-675-0358
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-26
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040264204C00000X, 207QS0010X
CT000406204C00000X, 207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Single Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT02849Medicare PIN