MEDICARE: VIRTUAL PHYSICIAN PRACTICE (NY), PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1457080939
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VIRTUAL PHYSICIAN PRACTICE (NY), PLLC

Provider Business Mailing Address
First Line	:	PO BOX 96361
Second Line	:
City	:	PHOENIX
State	:	AZ
Zip	:	85072-6361
Country	:	US
Telephone Number	:	518-510-1774
Fax Number	:	844-921-1079

Provider Business Practice Location Address
First Line	:	845 CENTRAL AVE STE 204
Second Line	:
City	:	ALBANY
State	:	NY
Zip	:	12206-1514
Country	:	US
Telephone Number	:	855-408-1143
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR OF RCM
Name	:	AUDRA JANE FICKEN
Credential	:
Telephone Number	:	734-373-0588

Provider Enumeration Date	:	06/09/2022
Last Update Date	:	04/07/2026

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