Provider Demographics
NPI:1659310092
Name:GREAT LAKES PHYSICIAN, PC
Entity Type:Organization
Organization Name:GREAT LAKES PHYSICIAN, PC
Other - Org Name:WESTERN NEW YORK UROLOGY ASSOCIATES LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:MANAGING PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:KAIRAV
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:CHEVLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-844-5000
Mailing Address - Street 1:3085 HARLEM RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:CHEEKTOWAGA
Mailing Address - State:NY
Mailing Address - Zip Code:14225-2591
Mailing Address - Country:US
Mailing Address - Phone:716-844-5000
Mailing Address - Fax:716-844-5050
Practice Address - Street 1:3085 HARLEM RD
Practice Address - Street 2:SUITE 350
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225-2591
Practice Address - Country:US
Practice Address - Phone:716-844-5000
Practice Address - Fax:716-844-5050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-04
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Multi-Specialty
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory MedicineGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03869087Medicaid
NY14359AMedicare PIN
NYCE0205Medicare ID - Type UnspecifiedRR MEDICARE