Healthcare Provider Details

I. General information

NPI: 1164793808
Provider Name (Legal Business Name): LETTRICK FAMILY MEDICINE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/25/2012
Last Update Date: 01/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 COLUMBIA TPKE
CASTLETON NY
12033-9584
US

IV. Provider business mailing address

1528 COLUMBIA TPKE
CASTLETON NY
12033-9584
US

V. Phone/Fax

Practice location:
  • Phone: 518-466-2287
  • Fax: 518-477-1255
Mailing address:
  • Phone: 518-466-2287
  • Fax: 518-477-1255

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number189372
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL A LETTRICK
Title or Position: CEO
Credential: MD
Phone: 518-466-2287