Provider Demographics
NPI:1073674412
Name:VANGUARD MEDICAL GROUP, P.A.
Entity Type:Organization
Organization Name:VANGUARD MEDICAL GROUP, P.A.
Other - Org Name:TOWN MEDICAL ASSOCIATES, P.A.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:RONISHA
Authorized Official - Middle Name:KATRINA
Authorized Official - Last Name:SCALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-559-3700
Mailing Address - Street 1:271 GROVE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1730
Mailing Address - Country:US
Mailing Address - Phone:973-559-3700
Mailing Address - Fax:973-559-8650
Practice Address - Street 1:271 GROVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1730
Practice Address - Country:US
Practice Address - Phone:973-239-2600
Practice Address - Fax:833-495-1921
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty
No207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ526340Medicare PIN