=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497566780
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VISAVIS HEALTH CARE MEDICAL GROUP OF VT PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2025
-----------------------------------------------------
Last Update Date | 01/15/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 105 CHESTER RD
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | VT
-----------------------------------------------------
Zip | 05156-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-210-2373
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1481 MCDONALD AVE
-----------------------------------------------------
City | BROOKLYN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11230-4667
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP PATIENT CARE SERVICES AND SUCCES
-----------------------------------------------------
Name | IRINA YUFFA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 973-564-1057
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------