Provider Demographics
NPI:1740596741
Name:MOUNT VERNON MEDICAL PRACTICE
Entity Type:Organization
Organization Name:MOUNT VERNON MEDICAL PRACTICE
Other - Org Name:CHRISTOPHER ADUBOR PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:O
Authorized Official - Last Name:ADUBOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:914-666-1400
Mailing Address - Street 1:153 STEVENS AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2543
Mailing Address - Country:US
Mailing Address - Phone:914-666-1400
Mailing Address - Fax:914-666-0629
Practice Address - Street 1:153 STEVENS AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2543
Practice Address - Country:US
Practice Address - Phone:914-666-1400
Practice Address - Fax:914-666-0629
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-27
Last Update Date:2010-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192587208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01605527Medicaid
NY0C7231Medicare PIN
01605527Medicare UPIN