Healthcare Provider Details

I. General information

NPI: 1679514004
Provider Name (Legal Business Name): RONDOUT VALLEY FAMILY MED PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10 GAGNON DR
STONE RIDGE NY
12484-5120
US

IV. Provider business mailing address

PO BOX 547
STONE RIDGE NY
12484-0547
US

V. Phone/Fax

Practice location:
  • Phone: 845-687-9933
  • Fax: 845-687-9953
Mailing address:
  • Phone: 845-687-9933
  • Fax: 845-687-9953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number160527
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number008467-1
License Number StateNY

VIII. Authorized Official

Name: DR. PETER JAMES PETRULIS
Title or Position: PRESIDENT
Credential: D.O.
Phone: 845-687-9933