Healthcare Provider Details

I. General information

NPI: 1669964706
Provider Name (Legal Business Name): HURLEY AVENUE FAMILY MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2018
Last Update Date: 06/05/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GAGNON DR.
STONE RIDGE NY
12484
US

IV. Provider business mailing address

10 GAGNON DR.
STONE RIDGE NY
12484
US

V. Phone/Fax

Practice location:
  • Phone: 845-687-7455
  • Fax: 845-687-4685
Mailing address:
  • Phone: 845-687-7455
  • Fax: 845-687-4685

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MATTHIAS VONREUSNER
Title or Position: MD/PARTNER
Credential: MD
Phone: 845-338-2541