Provider Demographics
NPI:1871805697
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:PRESIDENT
Authorized Official - Prefix:
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 1:935 RAINBOW TRL
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-1034
Mailing Address - Country:US
Mailing Address - Phone:203-645-8859
Mailing Address - Fax:
Practice Address - Street 1:935 RAINBOW TRL
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-1034
Practice Address - Country:US
Practice Address - Phone:203-645-8859
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT040593208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty