Provider Demographics
NPI:1659452027
Name:VISTA MEDICAL SERVICES, INC.
Entity Type:Organization
Organization Name:VISTA MEDICAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:
Authorized Official - Last Name:DURLOFSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:302-598-7667
Mailing Address - Street 1:160 ROCK HILL RD FL 1
Mailing Address - Street 2:
Mailing Address - City:BALA CYNWYD
Mailing Address - State:PA
Mailing Address - Zip Code:19004-2133
Mailing Address - Country:US
Mailing Address - Phone:610-667-6080
Mailing Address - Fax:
Practice Address - Street 1:160 ROCK HILL RD FL 1
Practice Address - Street 2:
Practice Address - City:BALA CYNWYD
Practice Address - State:PA
Practice Address - Zip Code:19004-2133
Practice Address - Country:US
Practice Address - Phone:610-667-6080
Practice Address - Fax:610-668-1580
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2013-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0001045604Medicaid
DEG00339Medicare PIN
DE0001045604Medicaid
PA864453Medicare PIN