Provider Demographics
NPI:1538318050
Name:NEWPORT MEDICAL, PLLC
Entity Type:Organization
Organization Name:NEWPORT MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:MAY
Authorized Official - Last Name:NICKELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-502-4085
Mailing Address - Street 1:221 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PALMYRA
Mailing Address - State:NY
Mailing Address - Zip Code:14522-1127
Mailing Address - Country:US
Mailing Address - Phone:315-502-4085
Mailing Address - Fax:315-502-4086
Practice Address - Street 1:221 E MAIN ST
Practice Address - Street 2:
Practice Address - City:PALMYRA
Practice Address - State:NY
Practice Address - Zip Code:14522-1127
Practice Address - Country:US
Practice Address - Phone:315-502-4085
Practice Address - Fax:315-502-4086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-09
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212521261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP010212521OtherBLUE CHOICE
MDE045OtherPREFERRED CARE
NY01914272Medicaid
1142OtherBLUE CROSS/ BLUE SHIELD
NYBB6380Medicare PIN
1142OtherBLUE CROSS/ BLUE SHIELD