Provider Demographics
NPI:1386671816
Name:BLT MEDICAL GROUP, LLP
Entity Type:Organization
Organization Name:BLT MEDICAL GROUP, LLP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LEROY
Authorized Official - Middle Name:W
Authorized Official - Last Name:MCCUNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-651-0911
Mailing Address - Street 1:3719 UNION RD
Mailing Address - Street 2:SUITE 218
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4249
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1026 UNION RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3445
Practice Address - Country:US
Practice Address - Phone:716-712-1030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02782070Medicaid
NY02782070Medicaid
BA0918Medicare PIN