Basic Information
| Provider Information | |||||||||
| NPI: | 1184384034 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | VANGUARD PARTNER NETWORK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 271 GROVE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Practice Location | |||||||||
| Address1: | 271 GROVE AVE STE A | ||||||||
| Address2: | |||||||||
| City: | VERONA | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 070441731 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9735593700 | ||||||||
| FaxNumber: | 9735598650 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2021 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | CARRAZZONE | ||||||||
| AuthorizedOfficialFirstName: | PETER | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9735593701 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANGUARD HEALTH SOLUTIONS, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.