Provider Demographics
NPI:1417191149
Name:INTERLAKES ORTHOPAEDIC SURGERY, PC
Entity Type:Organization
Organization Name:INTERLAKES ORTHOPAEDIC SURGERY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:B
Authorized Official - Last Name:MARK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-789-0993
Mailing Address - Street 1:430 CLIFTON SPRINGS PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432-1037
Mailing Address - Country:US
Mailing Address - Phone:315-462-3501
Mailing Address - Fax:315-462-3503
Practice Address - Street 1:430 CLIFTON SPRINGS PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:CLIFTON SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:14432-1037
Practice Address - Country:US
Practice Address - Phone:315-462-3501
Practice Address - Fax:315-462-3503
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INTERLAKES ORTHOPAEDIC SURGERY, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-24
Last Update Date:2009-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01556830Medicaid
NY32989AMedicare PIN
NY01556830Medicaid