Provider Demographics
NPI:1144362575
Name:PICKARD, JAMES R
Entity type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:PICKARD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1075 WHITING RD
Mailing Address - Street 2:
Mailing Address - City:JORDAN
Mailing Address - State:NY
Mailing Address - Zip Code:13080-9749
Mailing Address - Country:US
Mailing Address - Phone:315-689-3896
Mailing Address - Fax:315-689-7280
Practice Address - Street 1:1075 WHITING RD
Practice Address - Street 2:
Practice Address - City:JORDAN
Practice Address - State:NY
Practice Address - Zip Code:13080-9749
Practice Address - Country:US
Practice Address - Phone:315-689-3896
Practice Address - Fax:315-689-7280
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161165267171WH0202X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No171WH0202XOther Service ProvidersContractorHome Modifications
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02082626OtherHCBS TBI MEDICAID WAIVER
NY01639303Medicaid
NY161165267OtherBC/BS
NY01639303Medicaid