Provider Demographics
NPI:1851665947
Name:MAVERICK FAMILY MEDICAL, PC
Entity Type:Organization
Organization Name:MAVERICK FAMILY MEDICAL, PC
Other - Org Name:MAVERICK FAMILY HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:KRAKOWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-657-7820
Mailing Address - Street 1:4080 STATE ROUTE 28 STE 1
Mailing Address - Street 2:
Mailing Address - City:BOICEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12412-5129
Mailing Address - Country:US
Mailing Address - Phone:845-657-7820
Mailing Address - Fax:845-657-6016
Practice Address - Street 1:4080 STATE ROUTE 28 STE 1
Practice Address - Street 2:
Practice Address - City:BOICEVILLE
Practice Address - State:NY
Practice Address - Zip Code:12412-5129
Practice Address - Country:US
Practice Address - Phone:845-657-7820
Practice Address - Fax:845-657-6016
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-07
Last Update Date:2012-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01907313Medicaid
NY01907313Medicaid