Provider Demographics
NPI:1306852181
Name:GREAT LAKES ANESTHESIOLOGY, PC
Entity Type:Organization
Organization Name:GREAT LAKES ANESTHESIOLOGY, PC
Other - Org Name:CGF ANESTHESIOLOGY ASSOCIATES, PC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:MEGAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ROEMER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-323-6570
Mailing Address - Street 1:1001 MAIN ST STE K3502
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:167-323-6570
Mailing Address - Fax:
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-6570
Practice Address - Fax:716-323-6658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-31
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01868253Medicaid
NY01868253Medicaid