Provider Demographics
NPI:1962417352
Name:KEUKA FAMILY PRACTICE ASSOCIATES LLP
Entity type:Organization
Organization Name:KEUKA FAMILY PRACTICE ASSOCIATES LLP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:W
Authorized Official - Last Name:O'CONNOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-776-2247
Mailing Address - Street 1:7573 STATE ROUTE 54
Mailing Address - Street 2:
Mailing Address - City:BATH
Mailing Address - State:NY
Mailing Address - Zip Code:14810-9504
Mailing Address - Country:US
Mailing Address - Phone:607-776-2247
Mailing Address - Fax:607-776-5919
Practice Address - Street 1:7573 STATE ROUTE 54
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-9504
Practice Address - Country:US
Practice Address - Phone:607-776-2247
Practice Address - Fax:607-776-5919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00457805Medicaid
NYAA0788Medicare ID - Type Unspecified