| Brockport Vine Medical Pc | |
|
122 West Ave Ste 6 Brockport NY 14420-1225 | |
| (585) 208-8668 | |
| Not Available |
| Full Name | Brockport Vine Medical Pc |
|---|---|
| Speciality | Internal Medicine |
| Location | 122 West Ave Ste 6, Brockport, New York |
| Authorized Official Name and Position | Alex Fahoury (OWNER) |
| Authorized Official Contact | 5852088668 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Brockport Vine Medical Pc 67 Sarah Cir Spencerport NY 14559-9592 Ph: (585) 208-8668 | Brockport Vine Medical Pc 122 West Ave Ste 6 Brockport NY 14420-1225 Ph: (585) 208-8668 |
| NPI Number | 1871144543 |
|---|---|
| Provider Enumeration Date | 09/24/2019 |
| Last Update Date | 01/03/2020 |
| Medicare PECOS PAC ID | 7214363530 |
|---|---|
| Medicare Enrollment ID | O20200205001677 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1871144543 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | (* (Not Available)) | Primary |
| Provider Name | Alex Fahoury |
|---|---|
| Provider Type | Practitioner - Internal Medicine |
| Provider Identifiers | NPI Number: 1467406934 PECOS PAC ID: 5799748737 Enrollment ID: I20051026000636 |
| Provider Name | Amber Lea Seeler |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629644547 PECOS PAC ID: 0941699722 Enrollment ID: I20211117000026 |
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