Provider Demographics
NPI:1912181660
Name:PORT JERVIS MEDICAL, PLLC
Entity Type:Organization
Organization Name:PORT JERVIS MEDICAL, PLLC
Other - Org Name:ADVANCED HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:RECKESS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-491-4164
Mailing Address - Street 1:32 PINE TREE DR
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603-5224
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32 PINE TREE DR
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603-5224
Practice Address - Country:US
Practice Address - Phone:845-462-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA123149Medicare PIN
NYWCK021Medicare PIN