Basic Information
| Provider Information | |||||||||
| NPI: | 1801104583 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH MEDICAL SERVICES JAMESTOWN CONVENIENCE CARE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JAMESTOWN CONVENIENCE CARE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 168 | ||||||||
| Address2: | 95 E CHAUTAUQUA ST | ||||||||
| City: | MAYVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147570168 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Practice Location | |||||||||
| Address1: | 320 PRATHER AVENUE | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | JAMESTOWN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 147016920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7167537107 | ||||||||
| FaxNumber: | 7167535367 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2010 | ||||||||
| LastUpdateDate: | 02/29/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BERKE | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 7167535315 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FAMILY HEALTH MEDICAL SERVICES, PLLC | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.