Provider Demographics
NPI:1033445481
Name:UPPER DELAWARE VALLEY INFECTIOUS DISEASES,PC
Entity Type:Organization
Organization Name:UPPER DELAWARE VALLEY INFECTIOUS DISEASES,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-794-6813
Mailing Address - Street 1:427 BROADWAY
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MONTICELLO
Mailing Address - State:NY
Mailing Address - Zip Code:12701-1742
Mailing Address - Country:US
Mailing Address - Phone:845-794-6813
Mailing Address - Fax:845-794-6816
Practice Address - Street 1:427 BROADWAY
Practice Address - Street 2:SUITE 1
Practice Address - City:MONTICELLO
Practice Address - State:NY
Practice Address - Zip Code:12701-1742
Practice Address - Country:US
Practice Address - Phone:845-794-6813
Practice Address - Fax:845-794-6816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01518258Medicaid