Basic Information
Provider Information | |||||||||
NPI: | 1548913767 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FAMILY HEALTH NETWORK OF CENTRAL NEW YORK, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 85 S WEST ST | ||||||||
Address2: |   | ||||||||
City: | HOMER | ||||||||
State: | NY | ||||||||
PostalCode: | 130771542 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6077533797 | ||||||||
FaxNumber: | 6077536677 | ||||||||
Practice Location | |||||||||
Address1: | 24 ALBRO RD | ||||||||
Address2: |   | ||||||||
City: | MARATHON | ||||||||
State: | NY | ||||||||
PostalCode: | 138032808 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6078493180 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/28/2022 | ||||||||
LastUpdateDate: | 01/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | OSBORNE | ||||||||
AuthorizedOfficialFirstName: | KIMBERLY | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 6077533797 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | FAMILY HEALTH NETWORK OF CENTRAL NEW YORK, INC | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/19/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
ID | Type | State | Issuer | Description | 00474144 | 05 | NY |   | MEDICAID |