Provider Demographics
NPI:1568618353
Name:WESTERN NEW YORK MED-PSYCH PLLC
Entity Type:Organization
Organization Name:WESTERN NEW YORK MED-PSYCH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SAMPATH
Authorized Official - Middle Name:
Authorized Official - Last Name:NEERUKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-324-3580
Mailing Address - Street 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:1001 E 2ND ST
Practice Address - Street 2:
Practice Address - City:COUDERSPORT
Practice Address - State:PA
Practice Address - Zip Code:16915-8161
Practice Address - Country:US
Practice Address - Phone:800-324-8820
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN NEW YORK MED-PSYCH PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-12
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD052162L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001713173Medicaid
PA001713173Medicaid
PAF05558Medicare UPIN