Provider Demographics
NPI:1578631669
Name:MONROE PRIMARY CARE MEDICAL PC
Entity Type:Organization
Organization Name:MONROE PRIMARY CARE MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BORIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LAVOTSHKIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-782-1714
Mailing Address - Street 1:PO BOX 834
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10949-0834
Mailing Address - Country:US
Mailing Address - Phone:845-782-1714
Mailing Address - Fax:845-782-6648
Practice Address - Street 1:745 ROUTE 17M
Practice Address - Street 2:SUITE 202
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-2660
Practice Address - Country:US
Practice Address - Phone:845-782-1714
Practice Address - Fax:845-782-6648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-30
Last Update Date:2012-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY61220207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02182598Medicaid
NY23S481Medicare PIN
NY02182598Medicaid