Basic Information
| Provider Information | |||||||||
| NPI: | 1033119599 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IBELLI | ||||||||
| FirstName: | VINCENT | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 155 CRYSTAL RUN RD | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109414028 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8457036999 | ||||||||
| FaxNumber: | 8457036297 | ||||||||
| Practice Location | |||||||||
| Address1: | 97 ROUTE 303 | ||||||||
| Address2: | |||||||||
| City: | TAPPAN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109832514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453595005 | ||||||||
| FaxNumber: | 8453592281 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2005 | ||||||||
| LastUpdateDate: | 02/10/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 167148-1 | NY | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01026815 | 05 | NY | MEDICAID |