Provider Demographics
NPI:1639209067
Name:WESTERN NEW YORK UROLOGY ASSOCIATES, LLC
Entity Type:Organization
Organization Name:WESTERN NEW YORK UROLOGY ASSOCIATES, LLC
Other - Org Name:JAMESTOWN DIVISION
Other - Org Type:Other Name
Authorized Official - Title/Position:PHYSICIAN PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:WALTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-488-1851
Mailing Address - Street 1:PO BOX 1094
Mailing Address - Street 2:WHOLESALE LOCKBOX CD2
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14240-1094
Mailing Address - Country:US
Mailing Address - Phone:716-488-1851
Mailing Address - Fax:
Practice Address - Street 1:117 FOOTE AVE
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-6947
Practice Address - Country:US
Practice Address - Phone:716-338-9200
Practice Address - Fax:716-338-9250
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN NEW YORK UROLOGY ASSOCIATES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-06
Last Update Date:2010-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Single Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01417481Medicaid
NYAA0101Medicare PIN
PA108727Medicare PIN