Provider Demographics
NPI:1821076308
Name:ELITE MEDICAL SUPPLY
Entity Type:Organization
Organization Name:ELITE MEDICAL SUPPLY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:NIKIEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-712-0881
Mailing Address - Street 1:1900 RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3332
Mailing Address - Country:US
Mailing Address - Phone:716-712-0881
Mailing Address - Fax:716-712-0882
Practice Address - Street 1:1900 RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3332
Practice Address - Country:US
Practice Address - Phone:716-712-0881
Practice Address - Fax:716-712-0882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-05
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic FitterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
000551490001OtherBLUE CROSS BLUE SHIELD
NY02752078Medicaid
8290875OtherINDEPENDENT HEALTH
NY02752078Medicaid