Provider Demographics
NPI:1972665719
Name:SAMUEL B PEARLSTEIN
Entity Type:Organization
Organization Name:SAMUEL B PEARLSTEIN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:PEARLSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:315-637-5500
Mailing Address - Street 1:512 TOWNE DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1331
Mailing Address - Country:US
Mailing Address - Phone:315-637-5500
Mailing Address - Fax:315-637-5588
Practice Address - Street 1:512 TOWNE DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1331
Practice Address - Country:US
Practice Address - Phone:315-637-5500
Practice Address - Fax:315-637-5588
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213E00000X, 213ES0000X, 213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1163200001Medicare NSC
NYAA0913Medicare ID - Type UnspecifiedGROUP