Provider Demographics
NPI:1972701530
Name:NORTH VALLEY MEDICAL, PC
Entity Type:Organization
Organization Name:NORTH VALLEY MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:COBURN
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:516-351-4046
Mailing Address - Street 1:25931 148TH DR
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-3001
Mailing Address - Country:US
Mailing Address - Phone:516-351-4046
Mailing Address - Fax:718-276-5083
Practice Address - Street 1:234-32 MERRICK BLVD
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422
Practice Address - Country:US
Practice Address - Phone:718-276-4482
Practice Address - Fax:718-276-5083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-05
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY198832207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM01617674Medicaid
NYS54403Medicare UPIN
NM01617674Medicaid
NYG20500Medicare UPIN