Healthcare Provider Details

I. General information

NPI: 1255772729
Provider Name (Legal Business Name): PRIMARY CARE HEALTH PARTNERS-ADIRONDACK LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2013
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

159 MARGARET ST SUITE 103
PLATTSBURGH NY
12901-1874
US

IV. Provider business mailing address

66 KNIGHT LN STE 10
WILLISTON VT
05495-9308
US

V. Phone/Fax

Practice location:
  • Phone: 518-562-0151
  • Fax: 518-562-2718
Mailing address:
  • Phone: 802-872-4327
  • Fax: 802-288-1144

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: JON ASSELIN
Title or Position: CHIEF OPERATING OFFICIER
Credential:
Phone: 802-872-4326