Provider Demographics
NPI:1023215662
Name:VITALOGY P.A.
Entity Type:Organization
Organization Name:VITALOGY P.A.
Other - Org Name:VITALOGY SKINCARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:RAMM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:512-930-3909
Mailing Address - Street 1:4513 WILLIAMS DR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-1302
Mailing Address - Country:US
Mailing Address - Phone:512-930-3909
Mailing Address - Fax:512-240-5469
Practice Address - Street 1:4513 WILLIAMS DR
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:TX
Practice Address - Zip Code:78633-1302
Practice Address - Country:US
Practice Address - Phone:512-930-3909
Practice Address - Fax:512-240-5469
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-28
Last Update Date:2017-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM5607207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Multi-Specialty
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00Y576Medicare PIN
301405Medicare PIN