1679514004 NPI number — RONDOUT VALLEY FAMILY MED PC

Table of content: (NPI 1679514004)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679514004 NPI number — RONDOUT VALLEY FAMILY MED PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RONDOUT VALLEY FAMILY MED 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:
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:
1679514004
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 547
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STONE RIDGE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12484-0547
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-687-9933
Provider Business Mailing Address Fax Number:
845-687-9953

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10 GAGNON DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STONE RIDGE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12484-5120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-687-9933
Provider Business Practice Location Address Fax Number:
845-687-9953
Provider Enumeration Date:
06/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
PETRULIS
Authorized Official First Name:
PETER
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
845-687-9933

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  160527 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X , with the licence number: 008467-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 10031715 . This is a "CDPHN" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 87726 . This is a "UNITED HEALTHCARE INS CO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 00950523 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3292 . This is a "GHI HMO SELECT" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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