Provider Demographics
NPI:1023322286
Name:ERROL S MCKENZIE MD PLLC
Entity type:Organization
Organization Name:ERROL S MCKENZIE MD PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PHYISICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERROL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKENZIE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-637-0477
Mailing Address - Street 1:212 HIGHBRIDGE ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:13066-1981
Mailing Address - Country:US
Mailing Address - Phone:315-637-0477
Mailing Address - Fax:315-637-0559
Practice Address - Street 1:212 HIGHBRIDGE ST
Practice Address - Street 2:SUITE C
Practice Address - City:FAYETTEVILLE
Practice Address - State:NY
Practice Address - Zip Code:13066-1981
Practice Address - Country:US
Practice Address - Phone:315-637-0477
Practice Address - Fax:315-637-0559
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-29
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222899207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
H50040Medicare UPIN