Provider Demographics
NPI:1346796398
Name:EASTERN NIAGARA MEDICAL GROUP
Entity Type:Organization
Organization Name:EASTERN NIAGARA MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:FRANCIS
Authorized Official - Last Name:ICKOWSKI
Authorized Official - Suffix:SR
Authorized Official - Credentials:MBA, CPA
Authorized Official - Phone:716-514-5501
Mailing Address - Street 1:521 EAST AVE
Mailing Address - Street 2:
Mailing Address - City:LOCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14094-3201
Mailing Address - Country:US
Mailing Address - Phone:716-514-5501
Mailing Address - Fax:716-514-5549
Practice Address - Street 1:53 ELIZABETH DR
Practice Address - Street 2:
Practice Address - City:LOCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14094-5226
Practice Address - Country:US
Practice Address - Phone:716-514-5501
Practice Address - Fax:716-514-5549
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTERN NIAGARA HOSPITAL, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-30
Last Update Date:2016-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3101000H207Q00000X, 207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354389Medicaid
NY3101000HOtherLICENSE NUMBER - OPERATING CERTIFICATE
NY330163Medicare Oscar/Certification