Provider Demographics
NPI:1972973345
Name:GREAT LAKES ERIE MEDICAL IMAGING LLC
Entity Type:Organization
Organization Name:GREAT LAKES ERIE MEDICAL IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SARAH
Authorized Official - Middle Name:
Authorized Official - Last Name:GLENN-SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:716-836-4646
Mailing Address - Street 1:199 PARK CLUB LN STE 300
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-5269
Mailing Address - Country:US
Mailing Address - Phone:716-836-4646
Mailing Address - Fax:716-836-4696
Practice Address - Street 1:462 GRIDER ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-3021
Practice Address - Country:US
Practice Address - Phone:716-898-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-29
Last Update Date:2015-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic RadiologyGroup - Single Specialty