Provider Demographics
NPI:1154071934
Name:EDEN PRIMARY CARE
Entity Type:Organization
Organization Name:EDEN PRIMARY CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIGID
Authorized Official - Middle Name:
Authorized Official - Last Name:O'GORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-575-7282
Mailing Address - Street 1:8274 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EDEN
Mailing Address - State:NY
Mailing Address - Zip Code:14057-1104
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8274 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:NY
Practice Address - Zip Code:14057-1104
Practice Address - Country:US
Practice Address - Phone:716-725-8114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-25
Last Update Date:2022-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY301295OtherNYS MEDICAL LICENSE