Provider Demographics
NPI:1326231291
Name:CHURCHVILLE-CHILI FAMILY MEDICINE, LLC
Entity Type:Organization
Organization Name:CHURCHVILLE-CHILI FAMILY MEDICINE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:HENRY
Authorized Official - Middle Name:MIKOLAJ
Authorized Official - Last Name:PASZKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:585-594-5994
Mailing Address - Street 1:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:N. CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514
Mailing Address - Country:US
Mailing Address - Phone:585-594-5995
Mailing Address - Fax:585-594-5425
Practice Address - Street 1:4201 BUFFALO RD
Practice Address - Street 2:BOX 505
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-1256
Practice Address - Country:US
Practice Address - Phone:585-594-5995
Practice Address - Fax:585-594-5425
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174814207Q00000X, 261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0535Medicare UPIN