Provider Demographics
NPI:1851497564
Name:BREAST CARE OF WESTERN NEW YORK L.L.C.
Entity Type:Organization
Organization Name:BREAST CARE OF WESTERN NEW YORK L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-332-6834
Mailing Address - Street 1:199 PARK CLUB LN
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5269
Mailing Address - Country:US
Mailing Address - Phone:716-332-6834
Mailing Address - Fax:716-332-6853
Practice Address - Street 1:199 PARK CLUB LN
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-5269
Practice Address - Country:US
Practice Address - Phone:716-332-6834
Practice Address - Fax:716-332-6853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2013-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1591702085R0001X
NY188498208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Multi-Specialty
No2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation OncologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1494Medicare ID - Type UnspecifiedPROVIDER NUMBER