Provider Demographics
NPI:1063927358
Name:PORT JERVIS FAMILY HEALTH NP PC
Entity type:Organization
Organization Name:PORT JERVIS FAMILY HEALTH NP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHELE
Authorized Official - Middle Name:M
Authorized Official - Last Name:DOYLE
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:845-856-6671
Mailing Address - Street 1:7 SURREY RD
Mailing Address - Street 2:
Mailing Address - City:CHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:10918-1106
Mailing Address - Country:US
Mailing Address - Phone:845-325-8378
Mailing Address - Fax:845-858-9903
Practice Address - Street 1:1 COLE ST
Practice Address - Street 2:
Practice Address - City:PORT JERVIS
Practice Address - State:NY
Practice Address - Zip Code:12771-2217
Practice Address - Country:US
Practice Address - Phone:845-856-6671
Practice Address - Fax:845-856-6671
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-08
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X
NY337610261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1902344492Medicaid
PA1035162650001Medicaid
NY1942551890Medicaid
NY05103104Medicaid