=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023322286
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ERROL S MCKENZIE MD PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/29/2010
-----------------------------------------------------
Last Update Date | 08/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 212 HIGHBRIDGE ST SUITE C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-637-0477
-----------------------------------------------------
Fax | 315-637-0559
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 212 HIGHBRIDGE ST SUITE C
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 13066-1981
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 315-637-0477
-----------------------------------------------------
Fax | 315-637-0559
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYISICIAN
-----------------------------------------------------
Name | DR. ERROL MCKENZIE
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 315-637-0477
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 222899
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------