Provider Demographics
NPI:1659774685
Name:VIP NEUROLOGY
Entity Type:Organization
Organization Name:VIP NEUROLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED PERSON
Authorized Official - Prefix:
Authorized Official - First Name:NIKOLAY
Authorized Official - Middle Name:
Authorized Official - Last Name:STAMBOLIYSKI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:321-751-0041
Mailing Address - Street 1:6105 N WICKHAM RD
Mailing Address - Street 2:#411682
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32941-7001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 FORTENBERRY RD
Practice Address - Street 2:
Practice Address - City:MERRITT ISLAND
Practice Address - State:FL
Practice Address - Zip Code:32952-3621
Practice Address - Country:US
Practice Address - Phone:321-325-1155
Practice Address - Fax:321-373-0055
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-05
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME812562084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261465100Medicaid
FL261465100Medicaid