Provider Demographics
NPI:1376209072
Name:VIVANT MEDICAL CARE PC
Entity Type:Organization
Organization Name:VIVANT MEDICAL CARE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SAMIR
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:201-282-7556
Mailing Address - Street 1:1025 LINDEN AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07657-1006
Mailing Address - Country:US
Mailing Address - Phone:201-282-7556
Mailing Address - Fax:
Practice Address - Street 1:1025 LINDEN AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07657-1006
Practice Address - Country:US
Practice Address - Phone:201-282-7556
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-17
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty