Provider Demographics
NPI:1023102209
Name:PHYSICAL MEDICINE AND CHIROPRACTIC CENTER LORELEI DAVIDSON M.D. MARC K
Entity type:Organization
Organization Name:PHYSICAL MEDICINE AND CHIROPRACTIC CENTER LORELEI DAVIDSON M.D. MARC K
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARC
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KIRSHNER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:203-975-7000
Mailing Address - Street 1:1867 SUMMER ST
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-5016
Mailing Address - Country:US
Mailing Address - Phone:203-975-7000
Mailing Address - Fax:203-975-0876
Practice Address - Street 1:1867 SUMMER ST
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5016
Practice Address - Country:US
Practice Address - Phone:203-975-7000
Practice Address - Fax:203-975-0876
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT044106204C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204C00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine, Sports MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4125747Medicaid
CT050001402CT01OtherLYNNE BC
CT050000952CT01OtherKIRSHNER BC
CT350000666Medicare ID - Type UnspecifiedKIRSHNER MEDICARE
CT4125747Medicaid