Provider Demographics
NPI:1871510636
Name:CONCORD MEDICAL GROUP PC
Entity Type:Organization
Organization Name:CONCORD MEDICAL GROUP PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PRISCILLA
Authorized Official - Middle Name:K
Authorized Official - Last Name:DALE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-592-3000
Mailing Address - Street 1:210 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14141-1442
Mailing Address - Country:US
Mailing Address - Phone:716-592-3600
Mailing Address - Fax:
Practice Address - Street 1:210 E MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:14141-1442
Practice Address - Country:US
Practice Address - Phone:716-592-3600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00619338Medicaid
NY30500GOtherEMPIRE
NY0003153OtherGHI
NYC31179OtherRR MEDICARE
NY048231Medicare PIN