Provider Demographics
NPI:1003889023
Name:VILLAGE INTERNAL MEDICINE GROUP
Entity Type:Organization
Organization Name:VILLAGE INTERNAL MEDICINE GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:DIBENEDETTO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-474-4000
Mailing Address - Street 1:710 MAIN STREET
Mailing Address - Street 2:VILLAGE INTERNAL MEDICINE GROUP
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777
Mailing Address - Country:US
Mailing Address - Phone:631-474-4000
Mailing Address - Fax:631-474-4011
Practice Address - Street 1:710 MAIN STREET
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777
Practice Address - Country:US
Practice Address - Phone:631-474-4000
Practice Address - Fax:631-474-4011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-09
Last Update Date:2010-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY172308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty