Provider Demographics
NPI:1013302355
Name:SOUTHERN NEW YORK PRIMARY CARE SERVICES IPA, LLC
Entity Type:Organization
Organization Name:SOUTHERN NEW YORK PRIMARY CARE SERVICES IPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:
Authorized Official - Last Name:KENEFICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-829-8550
Mailing Address - Street 1:3113 LAWTON ROAD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803
Mailing Address - Country:US
Mailing Address - Phone:888-829-8550
Mailing Address - Fax:855-418-9149
Practice Address - Street 1:1200 STATE ROUTE 208
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-4648
Practice Address - Country:US
Practice Address - Phone:888-829-8550
Practice Address - Fax:855-418-9149
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VAXCARE CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-03
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY153414207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PHC059OtherMEDICARE PTAN