1396899365 NPI number — WESTSIDE PODIATRY CENTER, LLP

Table of content: (NPI 1396899365)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396899365 NPI number — WESTSIDE PODIATRY CENTER, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WESTSIDE PODIATRY CENTER, LLP
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:
6
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:
1396899365
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8280 WILLETT PKWY
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
BALDWINSVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13027-1325
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-857-0140
Provider Business Mailing Address Fax Number:
315-857-0144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 FENNELL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SKANEATELES
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13152-1158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-685-3338
Provider Business Practice Location Address Fax Number:
315-685-6391
Provider Enumeration Date:
01/23/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FARRELL
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
PARTNER OWNER
Authorized Official Telephone Number:
315-857-0140

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X , with the licence number:  N003729 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02554983 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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