Provider Demographics
NPI:1821019050
Name:ONTARIO MEDICAL PRACTICE PC
Entity Type:Organization
Organization Name:ONTARIO MEDICAL PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:GILPIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-349-5511
Mailing Address - Street 1:PO BOX 645
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-0645
Mailing Address - Country:US
Mailing Address - Phone:315-349-5511
Mailing Address - Fax:315-349-5785
Practice Address - Street 1:110 W 6TH ST
Practice Address - Street 2:
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126-2507
Practice Address - Country:US
Practice Address - Phone:315-349-5511
Practice Address - Fax:315-349-5785
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207L00000X, 207Q00000X, 208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1496Medicare PIN