Provider Demographics
NPI:1831129865
Name:VICTORY INTERNAL MEDICINE, P.C.
Entity Type:Organization
Organization Name:VICTORY INTERNAL MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHYE
Authorized Official - Middle Name:
Authorized Official - Last Name:WORTMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-477-6900
Mailing Address - Street 1:2315 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6623
Mailing Address - Country:US
Mailing Address - Phone:718-477-6900
Mailing Address - Fax:
Practice Address - Street 1:2315 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6623
Practice Address - Country:US
Practice Address - Phone:718-477-6900
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201641207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCJ9386OtherRAILROAD MEDICARE GROUP#
NY2294955OtherAETNA HMO GROUP#
NY7585094OtherAETNA PPO GROUP#
NY=========OtherTAX IDENTIFICATION #
NY7585094OtherAETNA PPO GROUP#