Provider Demographics
NPI:1710309414
Name:CHS N.Y. MEDICAL P.C.
Entity Type:Organization
Organization Name:CHS N.Y. MEDICAL P.C.
Other - Org Name:GOODLIFE HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE VP
Authorized Official - Prefix:
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-760-0700
Mailing Address - Street 1:5500 MARYLAND WAY STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-4973
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14201
Practice Address - Country:US
Practice Address - Phone:716-879-8214
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHS HEALTH SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-01-15
Last Update Date:2014-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty