Provider Demographics
NPI:1538102850
Name:SEVERSON, AMY MARIE (MD)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:MARIE
Last Name:SEVERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5430 MAIN ST
Mailing Address - Street 2:EGEA MEDICAL WEIGHT LOSS CENTER
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-6648
Mailing Address - Country:US
Mailing Address - Phone:716-204-0707
Mailing Address - Fax:
Practice Address - Street 1:5430 MAIN ST
Practice Address - Street 2:EGEA MEDICAL WEIGHT LOSS CENTER
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-6648
Practice Address - Country:US
Practice Address - Phone:716-204-0707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2235651207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02504814Medicaid
DD8671Medicare PIN
AA1194Medicare PIN
DD7192Medicare ID - Type Unspecified
NYP00337696Medicare PIN
NY02504814Medicaid