Provider Demographics
NPI:1841433109
Name:LAKE COUNTRY FAMILY MEDICINE, P.C.
Entity Type:Organization
Organization Name:LAKE COUNTRY FAMILY MEDICINE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:W
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-394-1875
Mailing Address - Street 1:502 S MAIN ST
Mailing Address - Street 2:SUITE G
Mailing Address - City:CANANDAIGUA
Mailing Address - State:NY
Mailing Address - Zip Code:14424-2242
Mailing Address - Country:US
Mailing Address - Phone:585-394-1875
Mailing Address - Fax:866-285-9069
Practice Address - Street 1:502 S MAIN ST
Practice Address - Street 2:SUITE G
Practice Address - City:CANANDAIGUA
Practice Address - State:NY
Practice Address - Zip Code:14424-2242
Practice Address - Country:US
Practice Address - Phone:585-394-1875
Practice Address - Fax:866-285-9069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-15
Last Update Date:2009-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02048819Medicaid
NY02048819Medicaid