Basic Information
Provider Information | |||||||||
NPI: | 1205259611 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NY URGENT CARE PRACTICE, PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FIVE STAR URGENT CARE FAIRMOUNT | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 500 | ||||||||
Address2: |   | ||||||||
City: | ELLICOTTVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 147310500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7166999032 | ||||||||
FaxNumber: | 7166999035 | ||||||||
Practice Location | |||||||||
Address1: | 3504 W GENESEE ST | ||||||||
Address2: | STE 1B | ||||||||
City: | SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 132192008 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154010754 | ||||||||
FaxNumber: | 3154010755 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/22/2014 | ||||||||
LastUpdateDate: | 04/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | RADFORD | ||||||||
AuthorizedOfficialFirstName: | JOHN | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/OWNER | ||||||||
AuthorizedOfficialTelephone: | 7166999032 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QU0200X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Urgent Care |
No ID Information.