Provider Demographics
NPI:1275894875
Name:VINEYARD PERSONALIZED MEDICINE LLC
Entity Type:Organization
Organization Name:VINEYARD PERSONALIZED MEDICINE LLC
Other - Org Name:ENVIRONMENTAL HEALTH CENTER OF MARTHA'S VINEYARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:NAGY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-693-1300
Mailing Address - Street 1:24 COURNOYER RD
Mailing Address - Street 2:
Mailing Address - City:VINEYARD HAVEN
Mailing Address - State:MA
Mailing Address - Zip Code:02568-7625
Mailing Address - Country:US
Mailing Address - Phone:508-693-1300
Mailing Address - Fax:508-693-1305
Practice Address - Street 1:24 COURNOYER RD
Practice Address - Street 2:
Practice Address - City:WEST TISBURY
Practice Address - State:MA
Practice Address - Zip Code:02575
Practice Address - Country:US
Practice Address - Phone:508-693-1300
Practice Address - Fax:508-693-1305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-31
Last Update Date:2015-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA72590208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA11009334AMedicaid