Provider Demographics
NPI:1356447270
Name:SOUTHTOWNS INTERNAL MEDICINE PC
Entity Type:Organization
Organization Name:SOUTHTOWNS INTERNAL MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:R
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-825-0300
Mailing Address - Street 1:3320 NORTH BENZING ROAD
Mailing Address - Street 2:
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127-5138
Mailing Address - Country:US
Mailing Address - Phone:716-825-0300
Mailing Address - Fax:716-825-0303
Practice Address - Street 1:3320 N BENZING RD
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-1538
Practice Address - Country:US
Practice Address - Phone:716-825-0300
Practice Address - Fax:716-825-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY177472207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA0373Medicare UPIN