Healthcare Provider Details

I. General information

NPI: 1629600143
Provider Name (Legal Business Name): MT. VERNON SPINE AND JOINT MEDICINE PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

704 LOCUST ST
MT. VERNON NY
10552-2111
US

IV. Provider business mailing address

704 LOCUST ST
MT. VERNON NY
10552-2111
US

V. Phone/Fax

Practice location:
  • Phone: 914-699-6763
  • Fax: 914-699-0070
Mailing address:
  • Phone: 914-699-6763
  • Fax: 914-699-0070

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 Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. LANDIS LLOYD BARNES
Title or Position: PRESIDENT
Credential: D.O.
Phone: 914-699-6763