Provider Demographics
NPI:1710099304
Name:PREVENTIVE MEDICINE ASSOCIATES LLC
Entity Type:Organization
Organization Name:PREVENTIVE MEDICINE ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:BARRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-487-8109
Mailing Address - Street 1:5415 W GENESEE ST
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-2162
Mailing Address - Country:US
Mailing Address - Phone:315-487-8109
Mailing Address - Fax:315-487-5680
Practice Address - Street 1:5415 W GENESEE ST
Practice Address - Street 2:SUITE 301
Practice Address - City:CAMILLUS
Practice Address - State:NY
Practice Address - Zip Code:13031-2162
Practice Address - Country:US
Practice Address - Phone:315-487-8109
Practice Address - Fax:315-487-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01630184Medicaid
NY01630184Medicaid
NY01630184Medicaid