Provider Demographics
NPI:1033545454
Name:KENMORE URGENT CARE PLLC
Entity Type:Organization
Organization Name:KENMORE URGENT CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNERR
Authorized Official - Prefix:DR
Authorized Official - First Name:TARIK
Authorized Official - Middle Name:
Authorized Official - Last Name:ELIBOL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-876-7606
Mailing Address - Street 1:2949 ELMWOOD AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:KENMORE
Mailing Address - State:NY
Mailing Address - Zip Code:14217-1356
Mailing Address - Country:US
Mailing Address - Phone:716-876-7606
Mailing Address - Fax:716-876-7608
Practice Address - Street 1:2949 ELMWOOD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1356
Practice Address - Country:US
Practice Address - Phone:716-876-7606
Practice Address - Fax:716-876-7608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-17
Last Update Date:2013-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY102346261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00647865Medicaid
B71161Medicare UPIN
024961Medicare PIN