Basic Information
| Provider Information | |||||||||
| NPI: | 1851665947 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAVERICK FAMILY MEDICAL, PC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MAVERICK FAMILY HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4080 STATE ROUTE 28 STE 1 | ||||||||
| Address2: | |||||||||
| City: | BOICEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124125129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456577820 | ||||||||
| FaxNumber: | 8456576016 | ||||||||
| Practice Location | |||||||||
| Address1: | 4080 STATE ROUTE 28 STE 1 | ||||||||
| Address2: | |||||||||
| City: | BOICEVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 124125129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8456577820 | ||||||||
| FaxNumber: | 8456576016 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2012 | ||||||||
| LastUpdateDate: | 03/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KRAKOWER | ||||||||
| AuthorizedOfficialFirstName: | MARTIN | ||||||||
| AuthorizedOfficialMiddleName: | DAVID | ||||||||
| AuthorizedOfficialTitleorPosition: | VICE PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8456577820 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 01907313 | 05 | NY | MEDICAID |