Provider Demographics
NPI:1588965743
Name:SOUTHTOWNS FAMILY PRACTICE PC
Entity type:Organization
Organization Name:SOUTHTOWNS FAMILY PRACTICE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:K
Authorized Official - Last Name:MACLEAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-432-7760
Mailing Address - Street 1:3040 AMSDELL RD
Mailing Address - Street 2:
Mailing Address - City:HAMBURG
Mailing Address - State:NY
Mailing Address - Zip Code:14075-5835
Mailing Address - Country:US
Mailing Address - Phone:716-646-6700
Mailing Address - Fax:716-646-8515
Practice Address - Street 1:3040 AMSDELL RD
Practice Address - Street 2:
Practice Address - City:HAMBURG
Practice Address - State:NY
Practice Address - Zip Code:14075-5835
Practice Address - Country:US
Practice Address - Phone:716-646-6700
Practice Address - Fax:716-646-8515
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2016-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03299805Medicaid
J100038618Medicare PIN