Provider Demographics
NPI:1801827035
Name:HERMOGENES, ALICIA W (MD)
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:W
Last Name:HERMOGENES
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 173
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-0173
Mailing Address - Country:US
Mailing Address - Phone:716-894-5071
Mailing Address - Fax:716-894-5072
Practice Address - Street 1:2475 HARLEM ROAD
Practice Address - Street 2:
Practice Address - City:CHEEKTOWAGA
Practice Address - State:NY
Practice Address - Zip Code:14225
Practice Address - Country:US
Practice Address - Phone:716-894-5071
Practice Address - Fax:716-894-5072
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2014-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY195934207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP00107601OtherRAILROAD MEDICARE
NY00010075804OtherUNIVERA
NY000523567004OtherBLUE CROSS OF WNY
NY040426002383OtherFIDELIS
NY3407412OtherINDEPENDENT HEALTH
NY01552001Medicaid
NY3407412OtherINDEPENDENT HEALTH
NYF78589Medicare UPIN
NY01552001Medicaid
NY11991BMedicare PIN