1659491421 NPI number — FAIRMOUNT FAMILY MEDICINE PLLC

Table of content: (NPI 1659491421)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659491421 NPI number — FAIRMOUNT FAMILY MEDICINE PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRMOUNT FAMILY MEDICINE PLLC
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:
1659491421
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/29/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5006 WEST GENESEE STREET
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMILLUS
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13031-2326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
315-234-2342
Provider Business Mailing Address Fax Number:
315-234-0697

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5006 WEST GENESEE STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CAMILLUS
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13031-2326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
315-234-2342
Provider Business Practice Location Address Fax Number:
315-234-0697
Provider Enumeration Date:
03/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
JACKSON
Authorized Official First Name:
LELAND
Authorized Official Middle Name:
J
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
315-234-2342

Provider Taxonomy Codes

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

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





Copyright © 2007-2025 www.npivalidator.com