Provider Demographics
NPI:1679986574
Name:GENESEE VALLEY GROUP HEALTH
Entity Type:Organization
Organization Name:GENESEE VALLEY GROUP HEALTH
Other - Org Name:LIFETIME HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT OF OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:CARLASCIO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-389-6066
Mailing Address - Street 1:333 BUTTERNUT DR
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2141
Mailing Address - Country:US
Mailing Address - Phone:315-671-6951
Mailing Address - Fax:
Practice Address - Street 1:899 MAIN ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1109
Practice Address - Country:US
Practice Address - Phone:716-878-2700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY003001856Medicaid
NY003001856Medicaid