Provider Demographics
NPI:1811000979
Name:ORCHARD PARK FAMILY PRACTICE, PC
Entity Type:Organization
Organization Name:ORCHARD PARK FAMILY PRACTICE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:D.O. / PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEGRAVE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-662-5357
Mailing Address - Street 1:3670 SOUTH BENZING RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ORCHARD PARK
Mailing Address - State:NY
Mailing Address - Zip Code:14127
Mailing Address - Country:US
Mailing Address - Phone:716-662-5357
Mailing Address - Fax:716-662-2774
Practice Address - Street 1:3670 SOUTH BENZING RD
Practice Address - Street 2:SUITE A
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127
Practice Address - Country:US
Practice Address - Phone:716-662-5357
Practice Address - Fax:716-662-2774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02780692Medicaid