Provider Demographics
NPI:1013263052
Name:CCS MEDICAL, PLLC
Entity Type:Organization
Organization Name:CCS MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WON
Authorized Official - Middle Name:SAM
Authorized Official - Last Name:YI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-655-2690
Mailing Address - Street 1:45 SPINDRIFT DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-7889
Mailing Address - Country:US
Mailing Address - Phone:716-565-0355
Mailing Address - Fax:
Practice Address - Street 1:45 SPINDRIFT DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-7889
Practice Address - Country:US
Practice Address - Phone:716-565-0355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical OncologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03493785Medicaid
NY03493785Medicaid