Healthcare Provider Details

I. General information

NPI: 1972665719
Provider Name (Legal Business Name): SAMUEL B PEARLSTEIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 05/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 TOWNE DR
FAYETTEVILLE NY
13066-1331
US

IV. Provider business mailing address

512 TOWNE DR
FAYETTEVILLE NY
13066-1331
US

V. Phone/Fax

Practice location:
  • Phone: 315-637-5500
  • Fax: 315-637-5588
Mailing address:
  • Phone: 315-637-5500
  • Fax: 315-637-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number StateNY

VIII. Authorized Official

Name: MS. DEBRA L PEARLSTEIN
Title or Position: OFFICE MANAGER
Credential:
Phone: 315-637-5500