Provider Demographics
NPI:1427592195
Name:FOUR SEASONS MEDICAL OF WNY PC
Entity Type:Organization
Organization Name:FOUR SEASONS MEDICAL OF WNY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:DIRIENZO
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:716-984-2090
Mailing Address - Street 1:2625 HARLEM RD
Mailing Address - Street 2:STE 70
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-4031
Mailing Address - Country:US
Mailing Address - Phone:716-462-5552
Mailing Address - Fax:716-424-0790
Practice Address - Street 1:2625 HARLEM RD
Practice Address - Street 2:STE 70
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-4031
Practice Address - Country:US
Practice Address - Phone:716-462-5552
Practice Address - Fax:716-424-0790
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOUR SEASONS MEDICAL OF WNY PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-12-14
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195126261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service