Provider Demographics
NPI:1639231343
Name:FREEMAN, FORD (PA)
Entity Type:Individual
Prefix:
First Name:FORD
Middle Name:
Last Name:FREEMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 COULTER ROAD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:14432
Mailing Address - Country:US
Mailing Address - Phone:315-462-3571
Mailing Address - Fax:315-462-7478
Practice Address - Street 1:200 NORTH ST
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:NY
Practice Address - Zip Code:14456-1561
Practice Address - Country:US
Practice Address - Phone:315-787-5100
Practice Address - Fax:315-787-5108
Is Sole Proprietor?:No
Enumeration Date:2006-12-16
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004858-1363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00003450OtherR.R. MEDICARE
NYP019004858OtherBLUE CROSS
NY109527BOOtherPREFERRED CARE
NYR95011Medicare UPIN
NYDD4130Medicare ID - Type Unspecified