Healthcare Provider Details

I. General information

NPI: 1366500530
Provider Name (Legal Business Name): VITA MEDICAL CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

87 BERDAN AVE STE 2B
WAYNE NJ
07470-3210
US

IV. Provider business mailing address

87 BERDAN AVE STE 2B
WAYNE NJ
07470-3210
US

V. Phone/Fax

Practice location:
  • Phone: 973-692-9631
  • Fax: 973-692-1112
Mailing address:
  • Phone: 973-692-9631
  • Fax: 973-692-1112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMA 67715
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMA56945
License Number StateNJ

VIII. Authorized Official

Name: LISA MELSKY
Title or Position: DOCTOR
Credential: MD
Phone: 973-692-9631