Provider Demographics
NPI:1659491421
Name:FAIRMOUNT FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:FAIRMOUNT FAMILY MEDICINE PLLC
Other - Org Name:CAMILLUS FAMILY HEALTH ASSOC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LELAND
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-234-2342
Mailing Address - Street 1:5006 WEST GENESEE STREET
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2326
Mailing Address - Country:US
Mailing Address - Phone:315-234-2342
Mailing Address - Fax:315-234-0697
Practice Address - Street 1:5006 WEST GENESEE STREET
Practice Address - Street 2:
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2326
Practice Address - Country:US
Practice Address - Phone:315-234-2342
Practice Address - Fax:315-234-0697
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty