Provider Demographics
NPI:1720438161
Name:VITAL PHYSICIANS PLLC
Entity type:Organization
Organization Name:VITAL PHYSICIANS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:J
Authorized Official - Last Name:SKALECKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:401-241-7723
Mailing Address - Street 1:9393 N 90TH ST STE 102-557
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5040
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:702-453-5741
Practice Address - Street 1:520 ROSE LN
Practice Address - Street 2:
Practice Address - City:WICKENBURG
Practice Address - State:AZ
Practice Address - Zip Code:85390-1447
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:702-453-5741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-16
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ51880207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty