Provider Demographics
NPI:1659542827
Name:MIDDLE COUNTRY FAMILY MEDICINE P C
Entity Type:Organization
Organization Name:MIDDLE COUNTRY FAMILY MEDICINE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:RANDALL
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:631-580-1740
Mailing Address - Street 1:2539 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3551
Mailing Address - Country:US
Mailing Address - Phone:631-580-1740
Mailing Address - Fax:631-580-1955
Practice Address - Street 1:2539 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 5
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3551
Practice Address - Country:US
Practice Address - Phone:631-580-1740
Practice Address - Fax:631-580-1955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-17
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX77595Medicare UPIN
NYW39101Medicare PIN