Basic Information
| Provider Information | |||||||||
| NPI: | 1073674412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VANGUARD MEDICAL GROUP, P.A. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | TOWN MEDICAL ASSOCIATES, P.A. | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 GROVE AVE STE E | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 GROVE AVE | ||||||||
| Address2: | SUITE A | ||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441730 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9732392600 | ||||||||
| FaxNumber: | 8334881686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/12/2006 | ||||||||
| LastUpdateDate: | 08/16/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | SCALES | ||||||||
| AuthorizedOfficialFirstName: | RONISHA | ||||||||
| AuthorizedOfficialMiddleName: | KATRINA | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING SPECIALIST | ||||||||
| AuthorizedOfficialTelephone: | 9735593700 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | N | 193200000X MULTI-SPECIALTY GROUP | Dietary & Nutritional Service Providers | Dietitian, Registered | 207QS0010X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine | 207RG0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.