Basic Information
Provider Information | |||||||||
NPI: | 1093265456 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TRIBE513, PA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | VIDA GYNECOLOGY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 274 COMMONWEALTH DR | ||||||||
Address2: | SUITE A | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296154869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8647201299 | ||||||||
FaxNumber: | 8647201300 | ||||||||
Practice Location | |||||||||
Address1: | 274 COMMONWEALTH DR | ||||||||
Address2: | SUITE A | ||||||||
City: | GREENVILLE | ||||||||
State: | SC | ||||||||
PostalCode: | 296154869 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8647201299 | ||||||||
FaxNumber: | 8647201300 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2016 | ||||||||
LastUpdateDate: | 10/10/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OOSTDYK | ||||||||
AuthorizedOfficialFirstName: | MELISSA | ||||||||
AuthorizedOfficialMiddleName: | KAY | ||||||||
AuthorizedOfficialTitleorPosition: | COORDINATOR, PROVIDER RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 8647201299 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | TRIBE513, P.A. | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207VG0400X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | Gynecology | 207V00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.