Provider Demographics
NPI:1740649268
Name:VANGUARD MEDICAL GROUP, PA
Entity type:Organization
Organization Name:VANGUARD MEDICAL GROUP, PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:RONISHA
Authorized Official - Middle Name:KATRINA
Authorized Official - Last Name:SCALES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:973-559-3700
Mailing Address - Street 1:271 GROVE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:VERONA
Mailing Address - State:NJ
Mailing Address - Zip Code:07044-1730
Mailing Address - Country:US
Mailing Address - Phone:973-559-3700
Mailing Address - Fax:833-484-1686
Practice Address - Street 1:271 GROVE AVE STE E
Practice Address - Street 2:
Practice Address - City:VERONA
Practice Address - State:NJ
Practice Address - Zip Code:07044-1730
Practice Address - Country:US
Practice Address - Phone:973-559-3700
Practice Address - Fax:833-484-1686
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANGUARD MEDICAL GROUP, PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-11
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ526340Medicare UPIN