Healthcare Provider Details

I. General information

NPI: 1265544936
Provider Name (Legal Business Name): BIG FLATS PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 MAPLE ST SUITE 3
BIG FLATS NY
14814-9701
US

IV. Provider business mailing address

455 MAPLE ST SUITE 3
BIG FLATS NY
14814-9701
US

V. Phone/Fax

Practice location:
  • Phone: 607-562-3600
  • Fax: 607-562-8661
Mailing address:
  • Phone: 607-562-3600
  • Fax: 607-562-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number195749
License Number StateNY

VIII. Authorized Official

Name: DR. PAUL PETER POVANDA
Title or Position: STAFF PHYSICIAN
Credential: D.O.
Phone: 607-562-3000