Healthcare Provider Details

I. General information

NPI: 1194317834
Provider Name (Legal Business Name): VHI MEDICAL GROUP, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2021
Last Update Date: 06/17/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6416 SHERMAN PEAK CT
CASTLE PINES CO
80108-9492
US

IV. Provider business mailing address

38 MONTVALE AVE STE 315
STONEHAM MA
02180-2446
US

V. Phone/Fax

Practice location:
  • Phone: 248-891-1268
  • Fax:
Mailing address:
  • Phone: 248-891-1268
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JACOB KETEYIAN
Title or Position: PRESIDENT
Credential:
Phone: 488-911-2682