Provider Demographics
NPI:1013011006
Name:RACINE, MAURICE A (MD)
Entity Type:Individual
Prefix:
First Name:MAURICE
Middle Name:A
Last Name:RACINE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:828 STATE ROUTE 11
Practice Address - Street 2:
Practice Address - City:CHAMPLAIN
Practice Address - State:NY
Practice Address - Zip Code:12919-4966
Practice Address - Country:US
Practice Address - Phone:518-298-2691
Practice Address - Fax:518-298-8241
Is Sole Proprietor?:No
Enumeration Date:2006-09-11
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY139080207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00669049Medicaid
NYJ400079534Medicare PIN
NY00669049Medicaid