Provider Demographics
NPI:1679978647
Name:SCOTTSVILLE FAMILY MEDICINE, LLC
Entity type:Organization
Organization Name:SCOTTSVILLE FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:NIEBOER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-594-5995
Mailing Address - Street 1:P O BOX 45
Mailing Address - Street 2:32B MAIN STREET
Mailing Address - City:SCOTTSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14546-1353
Mailing Address - Country:US
Mailing Address - Phone:585-571-4868
Mailing Address - Fax:585-348-2100
Practice Address - Street 1:32B MAIN STREET
Practice Address - Street 2:
Practice Address - City:SCOTTSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14546-1353
Practice Address - Country:US
Practice Address - Phone:585-571-4868
Practice Address - Fax:585-348-2100
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-03
Last Update Date:2014-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty