Provider Demographics
NPI:1306032305
Name:SANDERSON MEDICAL PC
Entity Type:Organization
Organization Name:SANDERSON MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VIRGIL
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:SANDERSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-523-7186
Mailing Address - Street 1:8515 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIARWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11435-1849
Mailing Address - Country:US
Mailing Address - Phone:718-523-7186
Mailing Address - Fax:
Practice Address - Street 1:8515 MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-1849
Practice Address - Country:US
Practice Address - Phone:718-523-7186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-24
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY168193207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01000908Medicaid
NY01000908Medicaid
=========Medicare PIN