1578631669 NPI number — MONROE PRIMARY CARE MEDICAL PC

Table of content: (NPI 1578631669)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578631669 NPI number — MONROE PRIMARY CARE MEDICAL PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONROE PRIMARY CARE MEDICAL PC
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:
1578631669
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 834
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONROE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10949-0834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-782-1714
Provider Business Mailing Address Fax Number:
845-782-6648

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
745 ROUTE 17M
Provider Second Line Business Practice Location Address:
SUITE 202
Provider Business Practice Location Address City Name:
MONROE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10950-2660
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-782-1714
Provider Business Practice Location Address Fax Number:
845-782-6648
Provider Enumeration Date:
11/30/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LAVOTSHKIN
Authorized Official First Name:
BORIS
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
845-782-1714

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  61220 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02182598 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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