Healthcare Provider Details

I. General information

NPI: 1326065186
Provider Name (Legal Business Name): FINGER LAKES OTOLARYNGOLOGY, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 02/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1206 DRIVING PARK AVE
NEWARK NY
14513-1057
US

IV. Provider business mailing address

1206 DRIVING PARK AVE
NEWARK NY
14513-1057
US

V. Phone/Fax

Practice location:
  • Phone: 315-331-1313
  • Fax: 315-331-5828
Mailing address:
  • Phone: 315-331-1313
  • Fax: 315-331-5828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207YX0602X
TaxonomyOtolaryngic Allergy Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KAREN A VANBORTEL
Title or Position: PRACTICE MANAGER
Credential:
Phone: 315-331-1313