Basic Information
| Provider Information | |||||||||
| NPI: | 1376981415 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALI REEIS-MARTIN PHYSICIAN PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 601 GATES RD | ||||||||
| Address2: | STE 3 | ||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138502288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077729462 | ||||||||
| FaxNumber: | 6077721223 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 CHALBURN RD | ||||||||
| Address2: | |||||||||
| City: | VESTAL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138502880 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3052063375 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/11/2013 | ||||||||
| LastUpdateDate: | 06/11/2013 | ||||||||
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| AuthorizedOfficialLastName: | REEIS-MARTIN | ||||||||
| AuthorizedOfficialFirstName: | TALI | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3052063375 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 256048 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 03186629 | 05 | NY | MEDICAID |