Basic Information
Provider Information | |||||||||
NPI: | 1598722159 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | SPRINGVILLE PEDIATRICS, LLP | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 141411244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7165922832 | ||||||||
FaxNumber: | 7165924452 | ||||||||
Practice Location | |||||||||
Address1: | 25 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGVILLE | ||||||||
State: | NY | ||||||||
PostalCode: | 141411244 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7165922832 | ||||||||
FaxNumber: | 7165924452 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/27/2006 | ||||||||
LastUpdateDate: | 09/04/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CANAVAN | ||||||||
AuthorizedOfficialFirstName: | JAMES | ||||||||
AuthorizedOfficialMiddleName: | WILLIAM | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 7165922832 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 4699900001 | 01 |   | DME MEDICARE | OTHER | 02374683 | 05 | NY |   | MEDICAID |