Provider Demographics
NPI:1932794641
Name:CHIBISOV, VITALY
Entity Type:Individual
Prefix:
First Name:VITALY
Middle Name:
Last Name:CHIBISOV
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 MURRAY ST APT 8V
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10007-2285
Mailing Address - Country:US
Mailing Address - Phone:412-983-4087
Mailing Address - Fax:
Practice Address - Street 1:89 MURRAY ST APT 8V
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10007-2285
Practice Address - Country:US
Practice Address - Phone:412-983-4087
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-04
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator