Basic Information
| Provider Information | |||||||||
| NPI: | 1114114808 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | STAMFORD FAMILY PRACTICE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | AO FOX MEMORIAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | STAMFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 121671145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6076522000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1 NORTON AVE | ||||||||
| Address2: | |||||||||
| City: | ONEONTA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 138202629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6074315900 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/27/2007 | ||||||||
| LastUpdateDate: | 09/27/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | WRIGHT | ||||||||
| AuthorizedOfficialFirstName: | MARK | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6074315900 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 00279098 | 05 | NY | MEDICAID |