Provider Demographics
NPI:1053735886
Name:AMIDON MEDICAL GROUP PLLC
Entity type:Organization
Organization Name:AMIDON MEDICAL GROUP PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:D
Authorized Official - Last Name:AMIDON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:315-507-5081
Mailing Address - Street 1:2 ELLINWOOD DR
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-1102
Mailing Address - Country:US
Mailing Address - Phone:315-507-5081
Mailing Address - Fax:315-738-1663
Practice Address - Street 1:2 ELLINWOOD DR
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-1102
Practice Address - Country:US
Practice Address - Phone:315-507-5081
Practice Address - Fax:315-738-1663
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-14
Last Update Date:2019-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY192498208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty