Provider Demographics
NPI:1407127525
Name:KC MEDICAL CONCEPT, LLC
Entity Type:Organization
Organization Name:KC MEDICAL CONCEPT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:MOURTZIKOS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:631-509-4774
Mailing Address - Street 1:102B ROUTE 112
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-1018
Mailing Address - Country:US
Mailing Address - Phone:631-509-4774
Mailing Address - Fax:
Practice Address - Street 1:102B ROUTE 112
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-1018
Practice Address - Country:US
Practice Address - Phone:631-509-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-20
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center