Provider Demographics
NPI:1366547135
Name:VITIEVSKY, ELLEN
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
Last Name:VITIEVSKY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7664
Mailing Address - Street 2:
Mailing Address - City:NORTH BRUNSWICK
Mailing Address - State:NJ
Mailing Address - Zip Code:08902-7664
Mailing Address - Country:US
Mailing Address - Phone:201-866-3100
Mailing Address - Fax:201-866-0321
Practice Address - Street 1:5600 KENNEDY BLVD W
Practice Address - Street 2:SUITE 102
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-1256
Practice Address - Country:US
Practice Address - Phone:201-866-3100
Practice Address - Fax:201-866-0321
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2025-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07786200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0076937Medicaid
NJ087367TMKMedicare PIN
NJ0076937Medicaid