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General NPI Number Information
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NPI Number | 1659542827
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Entity Type | Organization
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Legal Business Name | MIDDLE COUNTRY FAMILY MEDICINE P C
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Dates
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Enumeration Date | 03/17/2008
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Last Update Date | 03/24/2014
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Provider Practice Location Address
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Address Line | 2539 MIDDLE COUNTRY RD SUITE 5
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City | CENTEREACH
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State | NY
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Zip | 11720-3551
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Country | US
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Telephone | 631-580-1740
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Fax | 631-580-1955
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Provider Business Mailing Address
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Address Line | 2539 MIDDLE COUNTRY RD SUITE 5
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City | CENTEREACH
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State | NY
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Zip | 11720-3551
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Country | US
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Telephone | 631-580-1740
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Fax | 631-580-1955
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL L. RANDALL
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Credential | D.O.
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Telephone | 631-580-1740
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 200458
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License Number State | NY
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