Provider Demographics
NPI:1467621797
Name:PROGRESSIVE MEDICINE OF ITHACA, PC
Entity Type:Organization
Organization Name:PROGRESSIVE MEDICINE OF ITHACA, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:WESTON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:607-272-9938
Mailing Address - Street 1:402 3RD STREET
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-9938
Mailing Address - Fax:607-272-9996
Practice Address - Street 1:402 3RD STREET
Practice Address - Street 2:SUITE 2
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-272-9938
Practice Address - Fax:607-272-9996
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY224502207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02383448Medicaid
NYBA1390Medicare PIN