NPIMap

Organization Active NPI

Fairport Baptist Homes

  • Skilled Nursing Facility
  • Fairport, NY
National Provider Identifier
1164435111
Registry record updated Oct 23, 2014
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
2725300N Issued in NY
Legal business name
FAIRPORT BAPTIST HOMES
Practice address
4646 Nine Mile Point Rd
Fairport, NY 14450-1163
Phone
(585) 388-2303
NPI assigned
Aug 14, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Oct 23, 2014

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Thomas H. Poelma
Title
President/Ceo
Phone
(585) 388-2300

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 2725300N NY Primary
Long Term Care Pharmacy 3336L0003X

Addresses

Primary practice location

4646 Nine Mile Point Rd
Fairport, NY 14450-1163

Mailing address

4646 Nine Mile Point Rd
Fairport, NY 14450-1163

Other identifiers 5

IdentifierTypeStateIssuer
105934CIOtherPREFERRED CARE
105934FQOtherPREFERRED CARE 'B'
P015005960OtherEXCELLUS BC/BS
00395657MedicaidNY
01703382MedicaidNY

Other names 1

  • Lifetimes Adult Day Health Care Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in NY

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040921001102 NY Part B Supplier - Clinic/Group Practice 8729050224 Receives reassigned benefits from 15 practitioners
Practice locations: Fairport, NY

National Provider Directory

National Provider Directory

Locations

4646 Fairport Nine Mile Point Rd
Fairport, NY 14450
Phone (585) 377-0350

Ownership & related parties

Subparts reporting this organization as parent 1

Organizations that report themselves as subparts in NPPES and name this organization, in the same state, as their parent.

Practitioners & affiliated clinicians

Practitioners 16

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

View all 16

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1155513600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1414022400000",
    "number": "1164435111",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4646 NINE MILE POINT RD",
            "city": "FAIRPORT",
            "state": "NY",
            "postal_code": "144501163"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4646 NINE MILE POINT RD",
            "city": "FAIRPORT",
            "state": "NY",
            "postal_code": "144501163",
            "telephone_number": "585-388-2303"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FAIRPORT BAPTIST HOMES",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-14",
        "last_updated": "2014-10-23",
        "status": "A",
        "authorized_official_last_name": "POELMA",
        "authorized_official_first_name": "THOMAS",
        "authorized_official_middle_name": "H.",
        "authorized_official_title_or_position": "PRESIDENT/CEO",
        "authorized_official_telephone_number": "585-388-2300",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "NY",
            "license": "2725300N",
            "primary": true
        },
        {
            "code": "3336L0003X",
            "taxonomy_group": "",
            "desc": "Pharmacy, Long Term Care Pharmacy",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED CARE",
            "identifier": "105934CI",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "PREFERRED CARE 'B'",
            "identifier": "105934FQ",
            "state": null
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "EXCELLUS BC/BS",
            "identifier": "P015005960",
            "state": null
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "00395657",
            "state": "NY"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01703382",
            "state": "NY"
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Lifetimes Adult Day Health Care",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Fairport, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 23, 2014; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.