Provider Demographics
NPI:1417452467
Name:PROVIDENCE MEDICAL SERVICES PLLC
Entity Type:Organization
Organization Name:PROVIDENCE MEDICAL SERVICES PLLC
Other - Org Name:AFC URGENT CARE MOUNT VERNON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DHARINI
Authorized Official - Middle Name:
Authorized Official - Last Name:SUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:860-212-9306
Mailing Address - Street 1:121 POVERTY HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06470-1800
Mailing Address - Country:US
Mailing Address - Phone:860-212-9306
Mailing Address - Fax:
Practice Address - Street 1:203 GRAMATAN AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-1291
Practice Address - Country:US
Practice Address - Phone:860-212-9306
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY287577261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care