Provider Demographics
NPI:1154497121
Name:GRAND ISLAND CHIROPRACTIC PC
Entity Type:Organization
Organization Name:GRAND ISLAND CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:NOTARO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:716-773-2222
Mailing Address - Street 1:2283 GRAND ISLAND BLVD
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:14072-1819
Mailing Address - Country:US
Mailing Address - Phone:716-773-2222
Mailing Address - Fax:866-907-6157
Practice Address - Street 1:2283 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072-1819
Practice Address - Country:US
Practice Address - Phone:716-773-2222
Practice Address - Fax:866-907-6157
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009041111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY8890392OtherINDEPENDENT HEALTH ID
NY000225223004OtherBLUE CROSS AND BLUE SHIEL
NYHC09041-7OtherWORKERS COMPENSATION
NYP00305508OtherRAILROAD MEDICARE ID
NY5801989OtherGHI
NY=========OtherCOMMUNITY BLUE
NY=========OtherPRISM
NY=========OtherAETNA
NYHC09041-7OtherWORKERS COMPENSATION
NY5801989OtherGHI
NYIA0937Medicare ID - Type UnspecifiedMEDICARE ID