Healthcare Provider Details

I. General information

NPI: 1639123862
Provider Name (Legal Business Name): PSYCHIATRIC NETWORK, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 12/17/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

567 FAIRMOUNT AVE
JAMESTOWN NY
14701-2775
US

IV. Provider business mailing address

PO BOX 41
JAMESTOWN NY
14702-0041
US

V. Phone/Fax

Practice location:
  • Phone: 716-664-5414
  • Fax: 716-664-4478
Mailing address:
  • Phone: 716-487-1124
  • Fax: 716-487-2488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number191390
License Number StateNY

VIII. Authorized Official

Name: BRADFORD FRANK
Title or Position: MD
Credential: MD
Phone: 716-664-5414