Provider Demographics
NPI:1609259969
Name:VITALE MEDICAL INC
Entity Type:Organization
Organization Name:VITALE MEDICAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:MIGUELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:BHUIYAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-990-6811
Mailing Address - Street 1:PO BOX 350
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0006
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3290 MEMORIAL DR STE B1
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-3400
Practice Address - Country:US
Practice Address - Phone:404-534-9692
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-06
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067173207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty