Provider Demographics
NPI:1932389517
Name:FAMILY OBSTETRICS-GYNECOLOGY PLLC
Entity Type:Organization
Organization Name:FAMILY OBSTETRICS-GYNECOLOGY PLLC
Other - Org Name:FAMILY OBSTETRICS-GYNECOLOGY
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:BRANCHAUD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:315-769-7777
Mailing Address - Street 1:15 HOSPITAL DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:MASSENA
Mailing Address - State:NY
Mailing Address - Zip Code:13662-1037
Mailing Address - Country:US
Mailing Address - Phone:315-769-7777
Mailing Address - Fax:
Practice Address - Street 1:15 HOSPITAL DR
Practice Address - Street 2:SUITE A
Practice Address - City:MASSENA
Practice Address - State:NY
Practice Address - Zip Code:13662-1037
Practice Address - Country:US
Practice Address - Phone:315-769-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-12
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY232251207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02563564Medicaid
NY02563564Medicaid