Provider Demographics
NPI:1679514004
Name:RONDOUT VALLEY FAMILY MED PC
Entity Type:Organization
Organization Name:RONDOUT VALLEY FAMILY MED PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:PETRULIS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:845-687-9933
Mailing Address - Street 1:PO BOX 547
Mailing Address - Street 2:
Mailing Address - City:STONE RIDGE
Mailing Address - State:NY
Mailing Address - Zip Code:12484-0547
Mailing Address - Country:US
Mailing Address - Phone:845-687-9933
Mailing Address - Fax:845-687-9953
Practice Address - Street 1:10 GAGNON DR
Practice Address - Street 2:
Practice Address - City:STONE RIDGE
Practice Address - State:NY
Practice Address - Zip Code:12484-5120
Practice Address - Country:US
Practice Address - Phone:845-687-9933
Practice Address - Fax:845-687-9953
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-09
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY160527207Q00000X
NY008467-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY10031715OtherCDPHN
NY87726OtherUNITED HEALTHCARE INS CO
NY00950523Medicaid
NY3292OtherGHI HMO SELECT
NYWXC851Medicare PIN
NY00950523Medicaid