1023317484 NPI number — VITALITY PHYSICIANS GROUP PRACTICE PC

Table of content: (NPI 1023317484)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023317484 NPI number — VITALITY PHYSICIANS GROUP PRACTICE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VITALITY PHYSICIANS GROUP PRACTICE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023317484
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/26/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3125 ROUTE 9W STE 204
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW WINDSOR
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12553-6764
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-502-3998
Provider Business Mailing Address Fax Number:
518-708-6889

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3125 ROUTE 9W
Provider Second Line Business Practice Location Address:
SUITE 204
Provider Business Practice Location Address City Name:
NEW WINDSOR
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12553-6764
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
914-502-3998
Provider Business Practice Location Address Fax Number:
518-708-6889
Provider Enumeration Date:
03/23/2011

Additional Information

Authorized Official

Authorized Official Last Name:
CABISUDO
Authorized Official First Name:
MITCHELL
Authorized Official Middle Name:
TAN
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
518-691-0732

Provider Taxonomy Codes

  • Taxonomy code: 2084P0800X , with the licence number:  257905 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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