1073701710 NPI number — FAMILY FOOTCARE GROUP, LLP

Table of content: (NPI 1073701710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073701710 NPI number — FAMILY FOOTCARE GROUP, LLP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY FOOTCARE GROUP, LLP
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1073701710
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
427 BROADWAY
Provider Second Line Business Mailing Address:
STE 2
Provider Business Mailing Address City Name:
MONTICELLO
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12701-1742
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-794-7741
Provider Business Mailing Address Fax Number:
845-794-0228

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 STATE ROUTE 17M
Provider Second Line Business Practice Location Address:
STE 17
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10950-4415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-492-8637
Provider Business Practice Location Address Fax Number:
845-794-0228
Provider Enumeration Date:
10/09/2007

Additional Information

Authorized Official

Authorized Official Last Name:
HUDES
Authorized Official First Name:
MARC
Authorized Official Middle Name:
J
Authorized Official Title or Position:
MANAGING PARTNER
Authorized Official Telephone Number:
845-794-7741

Provider Taxonomy Codes

  • Taxonomy code: 213ES0131X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0441090001 . This is a "MEDICARE DMERC" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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