Provider Demographics
NPI:1033107586
Name:VILLAGE OF FAYETTEVILLE
Entity Type:Organization
Organization Name:VILLAGE OF FAYETTEVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MAYOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:A
Authorized Official - Last Name:OLSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-637-9864
Mailing Address - Street 1:PO BOX 535
Mailing Address - Street 2:
Mailing Address - City:BALDWINSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13027-0535
Mailing Address - Country:US
Mailing Address - Phone:315-635-1789
Mailing Address - Fax:315-635-3289
Practice Address - Street 1:425 E GENESSE ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066
Practice Address - Country:US
Practice Address - Phone:315-637-9864
Practice Address - Fax:315-637-0106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3317341600000X
NY341600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes341600000XTransportation ServicesAmbulance
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00048271OtherRAILROAD MEDICARE
NY02377402Medicaid
NYP00048271OtherRAILROAD MEDICARE
NYP00048271OtherRAILROAD MEDICARE