Healthcare Provider Details

I. General information

NPI: 1003869066
Provider Name (Legal Business Name): NEW BERLIN FAMILY PRACTICE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 TERRACE HTS
NEW BERLIN NY
13411-9514
US

IV. Provider business mailing address

PO BOX 250 4 TERRACE HEIGHTS
NEW BERLIN NY
13411-0250
US

V. Phone/Fax

Practice location:
  • Phone: 607-847-6750
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ROGER J. HALBERT
Title or Position: CEO
Credential:
Phone: 607-847-7000