Provider Demographics
NPI:1326572181
Name:EAST VILLAGE INTEGRATED MEDICAL, PC
Entity Type:Organization
Organization Name:EAST VILLAGE INTEGRATED MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TARAS
Authorized Official - Middle Name:
Authorized Official - Last Name:ODULAK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:212-260-2213
Mailing Address - Street 1:33 E 7TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10003-8191
Mailing Address - Country:US
Mailing Address - Phone:212-260-2213
Mailing Address - Fax:212-260-2354
Practice Address - Street 1:33 E 7TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-8191
Practice Address - Country:US
Practice Address - Phone:212-260-2213
Practice Address - Fax:212-260-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-18
Last Update Date:2017-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006018111N00000X
NY264414207QS0010X, 2251S0007X
2251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSportsGroup - Multi-Specialty