Provider Demographics
NPI:1326133620
Name:DR. MARIA JEREVA
Entity Type:Organization
Organization Name:DR. MARIA JEREVA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARIA
Authorized Official - Middle Name:
Authorized Official - Last Name:JEREVA-SIMONOVA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-773-8925
Mailing Address - Street 1:908 NIAGARA FALLS BLVD
Mailing Address - Street 2:STE. 208
Mailing Address - City:N. TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120
Mailing Address - Country:US
Mailing Address - Phone:716-692-3302
Mailing Address - Fax:716-692-4342
Practice Address - Street 1:1801 GRAND ISLAND BLVD
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NY
Practice Address - Zip Code:14072
Practice Address - Country:US
Practice Address - Phone:716-773-8925
Practice Address - Fax:716-692-4342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-03
Last Update Date:2008-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239958207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02080115Medicaid
NYCC5983Medicare PIN
NY02080115Medicaid