Provider Demographics
NPI:1114116845
Name:COXSACKIE FAMILY PRACTICE
Entity Type:Organization
Organization Name:COXSACKIE FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SALVATORE
Authorized Official - Middle Name:
Authorized Official - Last Name:LICCIARDI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-731-7777
Mailing Address - Street 1:PO BOX 215
Mailing Address - Street 2:
Mailing Address - City:SLINGERLANDS
Mailing Address - State:NY
Mailing Address - Zip Code:12159-0215
Mailing Address - Country:US
Mailing Address - Phone:518-731-7777
Mailing Address - Fax:
Practice Address - Street 1:24 LAFAYETTE AVE
Practice Address - Street 2:
Practice Address - City:COXSACKIE
Practice Address - State:NY
Practice Address - Zip Code:12051-1305
Practice Address - Country:US
Practice Address - Phone:518-731-7777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-18
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY169373207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW31181Medicare PIN