Provider Demographics
NPI:1205857265
Name:GENESSEE VALLEY GROUP HEALTH ASSOC
Entity Type:Organization
Organization Name:GENESSEE VALLEY GROUP HEALTH ASSOC
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CYNTHIA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMBRES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-857-4587
Mailing Address - Street 1:2075 SHERIDAN DR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14223-1432
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2075 SHERIDAN DR
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14223-1432
Practice Address - Country:US
Practice Address - Phone:716-874-1850
Practice Address - Fax:716-879-3280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0273273336C0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0002XSuppliersPharmacyClinic Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619212Medicaid
3374686OtherOTHER ID NUMBER-COMMERCIAL NUMBER
1307940012Medicare ID - Type Unspecified