1417594623 NPI number — WYOMING COUNTY FAMILY MEDICINE PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417594623 NPI number — WYOMING COUNTY FAMILY MEDICINE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WYOMING COUNTY FAMILY MEDICINE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1417594623
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 N MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARSAW
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14569-1025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
585-786-8940
Provider Business Mailing Address Fax Number:
585-492-4681

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5596 GAINESVILLE ROAD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CASTILE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
585-793-9230
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/06/2019

Additional Information

Authorized Official

Authorized Official Last Name:
DEAHN
Authorized Official First Name:
DALE
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
585-492-5088

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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