Provider Demographics
NPI:1215028055
Name:PORT CITY FAMILY MEDICINE P.C. INC
Entity Type:Organization
Organization Name:PORT CITY FAMILY MEDICINE P.C. INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CORLISS
Authorized Official - Middle Name:ADAM
Authorized Official - Last Name:VARNUM
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-343-6974
Mailing Address - Street 1:33 E SCHUYLER ST
Mailing Address - Street 2:
Mailing Address - City:OSWEGO
Mailing Address - State:NY
Mailing Address - Zip Code:13126-1161
Mailing Address - Country:US
Mailing Address - Phone:315-343-6974
Mailing Address - Fax:315-342-3625
Practice Address - Street 1:33 E SCHUYLER ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-1161
Practice Address - Country:US
Practice Address - Phone:315-343-6974
Practice Address - Fax:315-342-3625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-27
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00964989Medicaid
NYAA1336Medicare ID - Type Unspecified