NPIMap

Organization Active NPI

Ellicottville Medical

  • Pediatrics Physician
  • Ellicottville, NY
National Provider Identifier
1902566748
Registry record updated Dec 21, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatrics PhysicianTaxonomy code 208000000X
Legal business name
ELLICOTTVILLE MEDICAL
Practice address
5 Park SQ
Ellicottville, NY 14731-7014
Phone
(716) 257-4397
NPI assigned
Dec 21, 2021
Last updated
Dec 21, 2021By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Dec 21, 2021

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

Authorized official

Name
Dr. Katelyn Johnson-Clark, DONPI 1285890939
Title
Owner
Phone
(941) 441-7804

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatrics Physician 208000000X NU Primary

Addresses

Primary practice location

5 Park SQ
Ellicottville, NY 14731-7014

Mailing address

PO Box 1252
Ellicottville, NY 14731-1252
Phone (716) 257-4397

Other identifiers 1

IdentifierTypeStateIssuer
261977OtherNYNYS MEDICAL LICENSE NUMBER

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address drkate@homegrownpeds.com

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

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

{
    "created_epoch": "1640044800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1640044800000",
    "number": "1902566748",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 1252",
            "city": "ELLICOTTVILLE",
            "state": "NY",
            "postal_code": "147311252",
            "telephone_number": "716-257-4397"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5 PARK SQ",
            "city": "ELLICOTTVILLE",
            "state": "NY",
            "postal_code": "147317014",
            "telephone_number": "716-257-4397"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "ELLICOTTVILLE MEDICAL",
        "organizational_subpart": "NO",
        "enumeration_date": "2021-12-21",
        "last_updated": "2021-12-21",
        "certification_date": "2021-12-21",
        "status": "A",
        "authorized_official_last_name": "JOHNSON-CLARK",
        "authorized_official_first_name": "KATELYN",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "941-441-7804",
        "authorized_official_name_prefix": "Dr.",
        "authorized_official_credential": "DO"
    },
    "taxonomies": [
        {
            "code": "208000000X",
            "taxonomy_group": "",
            "desc": "Pediatrics",
            "state": "NU",
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "NYS MEDICAL LICENSE NUMBER",
            "identifier": "261977",
            "state": "NY"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "drkate@homegrownpeds.com",
            "affiliation": "N",
            "address_1": "5 Park Sq",
            "city": "Ellicottville",
            "state": "NY",
            "country_code": "US",
            "postal_code": "147317014",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Ellicottville, NY

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 21, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.