Healthcare Provider Details

I. General information

NPI: 1184883555
Provider Name (Legal Business Name): NORTH COUNTRY FAMILY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 03/31/2020
Certification Date: 03/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

428 WASHINGTON ST STE 4
WATERTOWN NY
13601-4832
US

IV. Provider business mailing address

445 FACTORY ST PO BOX 91
WATERTOWN NY
13601-2729
US

V. Phone/Fax

Practice location:
  • Phone: 315-788-4880
  • Fax: 315-788-4896
Mailing address:
  • Phone: 315-782-4207
  • Fax: 315-782-8699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number227318
License Number StateNY

VIII. Authorized Official

Name: JON A EMERTON
Title or Position: OWNER/DIRECTOR
Credential: M.D.
Phone: 315-788-4880