Basic Information
Provider Information | |||||||||
NPI: | 1174941256 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NUVANCE HEALTH MEDICAL PRACTICE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NHMP WOUND CARE VBMC | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1351 ROUTE 55 | ||||||||
Address2: | SUITE 200 | ||||||||
City: | LAGRANGEVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 125405108 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454759661 | ||||||||
FaxNumber: | 8454759938 | ||||||||
Practice Location | |||||||||
Address1: | 21 FOX ST | ||||||||
Address2: | SUITE 104 | ||||||||
City: | POUGHKEEPSIE | ||||||||
State: | NY | ||||||||
PostalCode: | 126014724 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8454312400 | ||||||||
FaxNumber: | 8454858199 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/04/2014 | ||||||||
LastUpdateDate: | 06/09/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | DARCY | ||||||||
AuthorizedOfficialFirstName: | KAREN | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | VP FINANCE | ||||||||
AuthorizedOfficialTelephone: | 2037394593 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/09/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |   | 207R00000X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208600000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.