Healthcare Provider Details

I. General information

NPI: 1013302355
Provider Name (Legal Business Name): SOUTHERN NEW YORK PRIMARY CARE SERVICES IPA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2015
Last Update Date: 04/27/2021
Certification Date: 04/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 STATE ROUTE 208
MONROE NY
10950-4648
US

IV. Provider business mailing address

3113 LAWTON ROAD SUITE 250
ORLANDO FL
32803
US

V. Phone/Fax

Practice location:
  • Phone: 888-829-8550
  • Fax: 855-418-9149
Mailing address:
  • Phone: 888-829-8550
  • Fax: 855-418-9149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number153414
License Number StateNY

VIII. Authorized Official

Name: MR. BRETT KENEFICK
Title or Position: PRESIDENT
Credential:
Phone: 888-829-8550