Provider Demographics
NPI:1770763617
Name:VILLAGE MEDICAL OF CNY, PC
Entity type:Organization
Organization Name:VILLAGE MEDICAL OF CNY, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER & OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:C
Authorized Official - Last Name:BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-457-7800
Mailing Address - Street 1:PO BOX 340
Mailing Address - Street 2:4350 MIDDLE SETTLEMENT RD SUITE C
Mailing Address - City:NEW HARTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13413-0340
Mailing Address - Country:US
Mailing Address - Phone:315-732-9368
Mailing Address - Fax:315-732-9403
Practice Address - Street 1:7523 MORGAN RD
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-3538
Practice Address - Country:US
Practice Address - Phone:315-457-7800
Practice Address - Fax:315-457-7453
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223034-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty