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General NPI Number Information
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NPI Number | 1659491421
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Entity Type | Organization
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Legal Business Name | FAIRMOUNT FAMILY MEDICINE PLLC
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Dates
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Enumeration Date | 03/29/2007
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Last Update Date | 11/29/2023
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Provider Practice Location Address
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Address Line | 5006 WEST GENESEE STREET
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City | CAMILLUS
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State | NY
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Zip | 13031-2326
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Country | US
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Telephone | 315-234-2342
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Fax | 315-234-0697
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Provider Business Mailing Address
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Address Line | 5006 WEST GENESEE STREET
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City | CAMILLUS
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State | NY
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Zip | 13031-2326
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Country | US
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Telephone | 315-234-2342
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Fax | 315-234-0697
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Authorized Official
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Title or Position | OWNER
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Name | DR. LELAND J JACKSON
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Credential | MD
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Telephone | 315-234-2342
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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