Basic Information
| Provider Information | |||||||||
| NPI: | 1508816695 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | AUBURN INTERNAL MEDICINE AND PEDIATRICS, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 161 GENESEE ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130213451 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152550947 | ||||||||
| FaxNumber: | 3152550942 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 GENESEE ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AUBURN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 130212662 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3152550947 | ||||||||
| FaxNumber: | 3152550942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 10/27/2014 | ||||||||
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| AuthorizedOfficialLastName: | GRANEY | ||||||||
| AuthorizedOfficialFirstName: | JOSEPH | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER/PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3152550947 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02022640 | 05 | NY | MEDICAID |