Provider Demographics
NPI:1891765244
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:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:SIDNEY
Authorized Official - Last Name:RISSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-679-5271
Mailing Address - Street 1:404 ZENA RD
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:NY
Mailing Address - Zip Code:12498
Mailing Address - Country:US
Mailing Address - Phone:845-679-5271
Mailing Address - Fax:845-679-0726
Practice Address - Street 1:404 ZENA RD
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:NY
Practice Address - Zip Code:12498
Practice Address - Country:US
Practice Address - Phone:845-679-5271
Practice Address - Fax:845-679-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2010-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142652207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01907313Medicaid
NY1213350001OtherPTIN
NY01907313Medicaid