Provider Demographics
NPI:1417594623
Name:WYOMING COUNTY FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:WYOMING COUNTY FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DALE
Authorized Official - Middle Name:
Authorized Official - Last Name:DEAHN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-492-5088
Mailing Address - Street 1:400 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:NY
Mailing Address - Zip Code:14569-1025
Mailing Address - Country:US
Mailing Address - Phone:585-786-8940
Mailing Address - Fax:585-492-4681
Practice Address - Street 1:5596 GAINESVILLE ROAD
Practice Address - Street 2:
Practice Address - City:CASTILE
Practice Address - State:NY
Practice Address - Zip Code:14427
Practice Address - Country:US
Practice Address - Phone:585-793-9230
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WY CNTY COMM HOSP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2019-12-06
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty