Basic Information
| Provider Information | |||||||||
| NPI: | 1427258326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VASSALLO | ||||||||
| FirstName: | ANTHONY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 EDGEWATER ST | ||||||||
| Address2: | 6TH FLOOR | ||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103054900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182264324 | ||||||||
| FaxNumber: | 7182261039 | ||||||||
| Practice Location | |||||||||
| Address1: | 475 SEAVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182269158 | ||||||||
| FaxNumber: | 7182266964 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 12/16/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 245047 | NY | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02892226 | 05 | NY | MEDICAID | P00459973 | 01 | NY | RR MEDICARE ID | OTHER |