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General NPI Number Information
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NPI Number | 1407127525
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Entity Type | Organization
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Legal Business Name | KC MEDICAL CONCEPT, LLC
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Dates
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Enumeration Date | 01/20/2012
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Last Update Date | 04/23/2013
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Provider Practice Location Address
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Address Line | 102B ROUTE 112
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1018
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Country | US
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Telephone | 631-509-4774
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Fax |
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Provider Business Mailing Address
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Address Line | 102B ROUTE 112
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City | PORT JEFFERSON STATION
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State | NY
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Zip | 11776-1018
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Country | US
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Telephone | 631-509-4774
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | DR. KAREN MOURTZIKOS
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Credential | M.D
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Telephone | 631-509-4774
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State | NY
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