Provider Demographics
NPI:1922300516
Name:PEDIATRIC AND ADOLESCENT URGENT CARE OF WESTERN NEW YORK
Entity Type:Organization
Organization Name:PEDIATRIC AND ADOLESCENT URGENT CARE OF WESTERN NEW YORK
Other - Org Name:PEDS URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:
Authorized Official - Last Name:GRISANTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:716-807-7435
Mailing Address - Street 1:1800 MAPLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-2749
Mailing Address - Country:US
Mailing Address - Phone:716-636-5437
Mailing Address - Fax:716-636-5439
Practice Address - Street 1:1800 MAPLE RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-2749
Practice Address - Country:US
Practice Address - Phone:716-636-5437
Practice Address - Fax:716-636-5439
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-02
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176526261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01302767Medicaid
NY01302767Medicaid
NYW86907Medicare PIN