Basic Information
| Provider Information | |||||||||
| NPI: | 1255772729 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIMARY CARE HEALTH PARTNERS-ADIRONDACK LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 66 KNIGHT LN STE 10 | ||||||||
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| City: | WILLISTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054959308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8028724327 | ||||||||
| FaxNumber: | 8022881144 | ||||||||
| Practice Location | |||||||||
| Address1: | 159 MARGARET ST | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | PLATTSBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 129011874 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5185620151 | ||||||||
| FaxNumber: | 5185622718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2013 | ||||||||
| LastUpdateDate: | 12/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | ASSELIN | ||||||||
| AuthorizedOfficialFirstName: | JON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF OPERATING OFFICIER | ||||||||
| AuthorizedOfficialTelephone: | 8028724326 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.