Provider Demographics
NPI:1831200088
Name:SAMSON PACHIKARA MD PC
Entity type:Organization
Organization Name:SAMSON PACHIKARA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SAMSON
Authorized Official - Middle Name:A
Authorized Official - Last Name:PACHIKARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-797-2314
Mailing Address - Street 1:123 GENESEE ST
Mailing Address - Street 2:
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-2323
Mailing Address - Country:US
Mailing Address - Phone:315-797-2314
Mailing Address - Fax:315-797-0850
Practice Address - Street 1:123 GENESEE ST
Practice Address - Street 2:
Practice Address - City:NEW HARTFORD
Practice Address - State:NY
Practice Address - Zip Code:13413-2323
Practice Address - Country:US
Practice Address - Phone:315-797-2314
Practice Address - Fax:315-797-0850
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2010-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY221758207Q00000X
NY203801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01797153Medicaid
=========OtherEXCELLUS/BS
NYAA1624Medicare ID - Type Unspecified
=========OtherEXCELLUS/BS