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General NPI Number Information
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NPI Number | 1679514004
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Entity Type | Organization
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Legal Business Name | RONDOUT VALLEY FAMILY MED PC
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 10/09/2007
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Provider Practice Location Address
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Address Line | 10 GAGNON DR
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City | STONE RIDGE
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State | NY
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Zip | 12484-5120
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Country | US
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Telephone | 845-687-9933
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Fax | 845-687-9953
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Provider Business Mailing Address
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Address Line | PO BOX 547
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City | STONE RIDGE
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State | NY
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Zip | 12484-0547
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Country | US
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Telephone | 845-687-9933
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Fax | 845-687-9953
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. PETER JAMES PETRULIS
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Credential | D.O.
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Telephone | 845-687-9933
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 008467-1
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 160527
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License Number State | NY
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