Provider Demographics
NPI:1891706743
Name:WESTERN NEW YORK MED-PSYCH PLLC
Entity Type:Organization
Organization Name:WESTERN NEW YORK MED-PSYCH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:SAMPATH
Authorized Official - Middle Name:
Authorized Official - Last Name:NEERUKONDA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:607-324-1263
Mailing Address - Street 1:111 E 14TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMIRA HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:14903-1303
Mailing Address - Country:US
Mailing Address - Phone:607-734-9539
Mailing Address - Fax:607-734-6293
Practice Address - Street 1:476 CANISTEO ST
Practice Address - Street 2:
Practice Address - City:HORNELL
Practice Address - State:NY
Practice Address - Zip Code:14843-9768
Practice Address - Country:US
Practice Address - Phone:607-324-3580
Practice Address - Fax:607-324-3998
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WESTERN NEW YORK MED-PSYCH PLLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-10
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01488462Medicaid
NY01488462Medicaid
NYBA0741Medicare PIN
PA135815Medicare PIN