Provider Demographics
NPI:1164793808
Name:LETTRICK FAMILY MEDICINE PLLC
Entity Type:Organization
Organization Name:LETTRICK FAMILY MEDICINE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:LETTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-466-2287
Mailing Address - Street 1:1528 COLUMBIA TPKE
Mailing Address - Street 2:
Mailing Address - City:CASTLETON
Mailing Address - State:NY
Mailing Address - Zip Code:12033-9584
Mailing Address - Country:US
Mailing Address - Phone:518-466-2287
Mailing Address - Fax:518-477-1255
Practice Address - Street 1:1528 COLUMBIA TPKE
Practice Address - Street 2:
Practice Address - City:CASTLETON
Practice Address - State:NY
Practice Address - Zip Code:12033-9584
Practice Address - Country:US
Practice Address - Phone:518-466-2287
Practice Address - Fax:518-477-1255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY189372207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty