Healthcare Provider Details

I. General information

NPI: 1699183806
Provider Name (Legal Business Name): OGDENSBURG FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/31/2014
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

921 STATE ST
OGDENSBURG NY
13669-3347
US

IV. Provider business mailing address

921 STATE ST
OGDENSBURG NY
13669-3347
US

V. Phone/Fax

Practice location:
  • Phone: 315-393-9268
  • Fax: 315-393-3541
Mailing address:
  • Phone: 315-393-9268
  • Fax: 315-393-3541

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WYLON SPRINGSTEAD
Title or Position: OFFICE MANAGER
Credential: MD
Phone: 315-393-9268