Provider Demographics
NPI:1689879132
Name:THOMAS C SMALL MD PC
Entity Type:Organization
Organization Name:THOMAS C SMALL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:C
Authorized Official - Last Name:SMALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-626-4878
Mailing Address - Street 1:2821 WEHRLE DR
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7386
Mailing Address - Country:US
Mailing Address - Phone:716-626-4878
Mailing Address - Fax:716-626-7609
Practice Address - Street 1:6511 MAIN ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSVILLES
Practice Address - State:NY
Practice Address - Zip Code:14221-5835
Practice Address - Country:US
Practice Address - Phone:716-626-4878
Practice Address - Fax:716-626-7609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYA1493801207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00738138Medicaid
NY048804OtherINDEPENDENT HEALTH
NY00738138Medicaid