Provider Demographics
NPI:1164486627
Name:JAMESTOWN PEDIATRIC ASSOCIATES, LLP
Entity Type:Organization
Organization Name:JAMESTOWN PEDIATRIC ASSOCIATES, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:MARSH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-664-2589
Mailing Address - Street 1:816 FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-2519
Mailing Address - Country:US
Mailing Address - Phone:716-664-2589
Mailing Address - Fax:716-483-3050
Practice Address - Street 1:816 FAIRMOUNT AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-2519
Practice Address - Country:US
Practice Address - Phone:716-664-2589
Practice Address - Fax:716-483-3050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-13
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185568208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX ID