Provider Demographics
NPI:1275806036
Name:FULTON FAMILY MEDICINE PRACTICE PC
Entity Type:Organization
Organization Name:FULTON FAMILY MEDICINE PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ESTHER
Authorized Official - Middle Name:SERWADDA
Authorized Official - Last Name:LUBINGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-532-8049
Mailing Address - Street 1:1782 STATE ROUTE 48
Mailing Address - Street 2:
Mailing Address - City:FULTON
Mailing Address - State:NY
Mailing Address - Zip Code:13069-4108
Mailing Address - Country:US
Mailing Address - Phone:315-532-8049
Mailing Address - Fax:
Practice Address - Street 1:20 CANALVIEW MALL
Practice Address - Street 2:
Practice Address - City:FULTON
Practice Address - State:NY
Practice Address - Zip Code:13069-1735
Practice Address - Country:US
Practice Address - Phone:315-532-8049
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-09
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2618481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03444819Medicaid
NYJ100068789Medicare PIN