Provider Demographics
NPI:1376981415
Name:TALI REEIS-MARTIN PHYSICIAN PC
Entity Type:Organization
Organization Name:TALI REEIS-MARTIN PHYSICIAN PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TALI
Authorized Official - Middle Name:
Authorized Official - Last Name:REEIS-MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:305-206-3375
Mailing Address - Street 1:601 GATES RD
Mailing Address - Street 2:STE 3
Mailing Address - City:VESTAL
Mailing Address - State:NY
Mailing Address - Zip Code:13850-2288
Mailing Address - Country:US
Mailing Address - Phone:607-772-9462
Mailing Address - Fax:607-772-1223
Practice Address - Street 1:101 CHALBURN RD
Practice Address - Street 2:
Practice Address - City:VESTAL
Practice Address - State:NY
Practice Address - Zip Code:13850-2880
Practice Address - Country:US
Practice Address - Phone:305-206-3375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY256048207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03186629Medicaid